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Ju JY, Escobar DJ, Xue Y, Booth AL, Nguyen J, Yang GY. Small bowel pyloric metaplasia is associated with lower rates of earlier recurrence of Crohn's disease after resection. Hum Pathol 2024; 151:105629. [PMID: 39029533 DOI: 10.1016/j.humpath.2024.105629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 07/04/2024] [Accepted: 07/16/2024] [Indexed: 07/21/2024]
Abstract
Recurrence within one or two years is common after Crohn's disease (CD) resection. In this study, we seek to identify histologic features in CD resections that may predict earlier (≤18 months) recurrence to potentially guide post-operative management. A single-institution, retrospective review was performed on patients with first-time CD bowel resection specimens (2002-2007). Patient demographics and CD course were also documented. Slides were reviewed for inflammatory distribution and composition, small bowel (SB) pyloric metaplasia (PM), and presence and characteristics of submucosal fibrosis and granulomas. In our cohort, 14 of 41 patients experienced earlier clinical or endoscopic recurrence after initial resection. In the 38 patients who underwent SB resection (3 were colon only), PM was less common in those with earlier recurrence (6/12 [50%]) compared to those with later (>18 months) or no known recurrence (22/26 [85%]) (P = 0.045). PM was present even in patients with <1 year of known CD. Additionally, therapy with anti-tumor necrosis factor (TNF) prior to surgery was more common in earlier recurrence patients (7/14 [50%]) than later or no recurrence patients (4/27 [15%]) (P = 0.026). There was no significant difference in age, sex, smoking status, duration of CD, post-operative CD medication, distribution or features of inflammation, granulomas, or fibrosis. Overall, our results indicate that SB PM and pre-surgical anti-TNF therapy are possible helpful clinicopathologic features to evaluate for recurrence risk.
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Affiliation(s)
- Jennifer Y Ju
- Department of Pathology, Northwestern University, 251 E Huron St, Chicago, Illinois, 60611, USA.
| | - David J Escobar
- Department of Pathology, Northwestern University, 251 E Huron St, Chicago, Illinois, 60611, USA
| | - Yue Xue
- Department of Pathology, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH, 44106, USA
| | - Adam L Booth
- Department of Pathology, Washington University in St. Louis, 660 S Euclid Ave, St. Louis, Missouri, 63110, USA
| | - Jessica Nguyen
- Department of Pathology, Northwestern University, 251 E Huron St, Chicago, Illinois, 60611, USA
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University, 251 E Huron St, Chicago, Illinois, 60611, USA
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2
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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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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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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: 2.0] [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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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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The Revival of Surgery in Crohn's Disease-Early Intestinal Resection as a Reasonable Alternative in Localized Ileitis. Biomedicines 2021; 9:biomedicines9101317. [PMID: 34680434 PMCID: PMC8533348 DOI: 10.3390/biomedicines9101317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 12/20/2022] Open
Abstract
Crohn's disease (CD) represents a heterogeneous and complex disease with no curative therapeutic option available to date. Current therapy is mainly antibody-based focusing on the immune system while other treatment alternatives such as surgery are considered to be "last options". However, medical therapy for CD results in mild to severe side effects in a relevant amount of patients and some patients do not respond to the medication. Following that, quality of life is often significantly reduced in this patient cohort, thus, therapeutic alternatives are urgently needed. Updated evidence has revealed that surgery such as ileocecal resection (ICR) might be a potential therapeutic option in case of localized terminal ileitis since resection at early time points improves quality of life and significantly reduces the postoperative need for immunosuppressive medication with low rates of morbidity. In addition, new surgical approaches such as Kono-S anastomosis or inclusion of the mesentery result in significantly reduced rates of disease recurrence and reoperation. Based on the new evidence, the goal of this review is to provide an update on the role of surgery as a reasonable alternative to medical therapy in the interdisciplinary treatment of patients with CD.
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