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Triantafillidis JK. Surgical treatment of inflammatory bowel disease: From the gastroenterologist's stand-point. World J Gastrointest Surg 2024; 16:1235-1254. [PMID: 38817292 PMCID: PMC11135302 DOI: 10.4240/wjgs.v16.i5.1235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 03/17/2024] [Accepted: 04/24/2024] [Indexed: 05/23/2024] Open
Abstract
Treatment of ulcerative colitis (UC) and Crohn's disease (CD) represents, in the majority of cases, a real challenge to the gastroenterologist's abilities and skills as well as a clinical test concerning his/her levels of medical knowledge and experience. During the last two decades, our pharmaceutical arsenal was significantly strengthened, especially after the introduction of the so-called biological agents, drugs which to a large extent not only improved the results of conservative treatment but also changed the natural history of the disease. However, colectomy is still necessary for some patients with severe UC although smaller compared to the past, precisely because of the improvements achieved in the available conservative treatment. Nevertheless, surgeries to treat colon dysplasia and cancer are increasing to some extent. At the same time, satisfactory improvements in surgical techniques, the pre-and post-operative care of patients, as well as the selection of the appropriate time for performing the surgery have been noticed. Regarding patients with CD, the improvement of conservative treatment did not significantly change the need for surgical treatment since two-thirds of patients need to undergo surgery at some point in the course of their disease. On the other hand, the outcome of the operation has improved through good preoperative care as well as the wide application of more conservative surgical techniques aimed at keeping as much of the bowel in situ as possible. This article discusses the indications for surgical management of UC patients from the gastroenterologist's point of view, the results of the emerging new techniques such as transanal surgery and robotics, as well as alternative operations to the classic ileo-anal-pouch anastomosis. The author also discusses the basic principles of surgical management of patients with CD based on the results of the relevant literature. The self-evident is emphasized, that is, to achieve an excellent therapeutic result in patients with severe inflammatory bowel disease in today's era; the close cooperation of gastroenterologists with surgeons, pathologists, imaging, and nutritionists is of paramount importance.
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Affiliation(s)
- John K Triantafillidis
- Inflammatory Bowel Disease Unit, “Metropolitan General” Hospital, Holargos 15562, Attica, Greece
- Hellenic Society of Gastrointestinal Oncology, Haidari 12461, Athens, Greece
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Abdulkarim S, Salama E, Pang AJ, Morin N, Ghitulescu G, Faria J, Vasilevsky CA, Boutros M. Extended versus limited mesenteric excision for operative Crohn's disease: 30-Day outcomes from the ACS-NSQIP database. Int J Colorectal Dis 2023; 38:268. [PMID: 37978997 DOI: 10.1007/s00384-023-04561-z] [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: 11/08/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE Recent studies have suggested that extended mesenteric excision (ME) may reduce surgical reintervention in Crohn's Disease (CD), but there remains clinical concerns regarding potential peri-operative morbidity. This retrospective study compares 30-day perioperative morbidity between limited and extended ME in segmental colectomies for CD. METHODS Using the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) colectomy-specific database, all patients with CD undergoing segmental colectomy for non-malignant indications between 2014-2019 were included. A lymph node harvest of 12 or more nodes was used as a surrogate for extended ME. The primary outcome was NSQIP major morbidity. Secondary outcomes included abdominal complications and perioperative bleeding. RESULTS Of 3,709 patients included from the ACS-NSQIP database, 3,087 underwent limited ME and 622 underwent extended ME. On univariate analysis, those with limited mesenteric excision were less likely to be anemic (46.1% vs 55.0%, p < 0.001) and have undergone an open surgery (44.7% vs 34.7%, p < 0.001). On univariate comparison of limited and extended ME, there was no significant difference in major morbidity. On multiple logistic regression, controlling for age, sex, BMI, smoking, preoperative sepsis, preoperative anemia, surgical approach, emergency surgery, stoma creation, bowel preparation, and immunosuppression, the extent of ME was not an independent predictor of NSQIP major morbidity (OR 1.1, 95% CI 0.84-1.44). Likewise, the extent of ME was not associated with an increase in abdominal complications (OR 0.95, 95% CI 0.76-1.19) or post-operative bleeding (OR 1.89, 95% CI 0.75-1.53). CONCLUSION Extended ME for CD was not associated with an increase in 30-day perioperative major morbidity.
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Affiliation(s)
- Shafic Abdulkarim
- Department of Surgery, McGill University, Jewish General Hospital, 3755 Cote Ste Catherine, G-317, Montreal, QC, Canada.
| | - Ebram Salama
- Department of Surgery, McGill University, Jewish General Hospital, 3755 Cote Ste Catherine, G-317, Montreal, QC, Canada
| | - Allison J Pang
- Department of Surgery, McGill University, Jewish General Hospital, 3755 Cote Ste Catherine, G-317, Montreal, QC, Canada
| | - Nancy Morin
- Department of Surgery, McGill University, Jewish General Hospital, 3755 Cote Ste Catherine, G-317, Montreal, QC, Canada
| | - Gabriela Ghitulescu
- Department of Surgery, McGill University, Jewish General Hospital, 3755 Cote Ste Catherine, G-317, Montreal, QC, Canada
| | - Julio Faria
- Department of Surgery, McGill University, Jewish General Hospital, 3755 Cote Ste Catherine, G-317, Montreal, QC, Canada
| | - Carol-Ann Vasilevsky
- Department of Surgery, McGill University, Jewish General Hospital, 3755 Cote Ste Catherine, G-317, Montreal, QC, Canada
| | - Marylise Boutros
- Department of Surgery, McGill University, Jewish General Hospital, 3755 Cote Ste Catherine, G-317, Montreal, QC, Canada
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Functional outcomes of transanal versus transabdominal restorative proctectomy with ileal pouch-anal anastomosis in ulcerative colitis-a monocentric retrospective comparative study. Langenbecks Arch Surg 2022; 407:3607-3614. [PMID: 35945298 DOI: 10.1007/s00423-022-02640-3] [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: 05/09/2022] [Accepted: 08/01/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) ensures satisfactory gastro-intestinal function and quality of life (QoL) in patients with refractory ulcerative colitis (UC). The transanal approach to proctectomy and IPAA (Ta-IPAA) has been developed to address the technical shortfalls of the traditional transabdominal approach (Tabd-IPAA). Ta-IPAA has proven to be safe but there is lack of reported functional outcomes. Aim of this study is to compare functional outcomes and QoL after Ta- or Tabd-IPAA for UC. METHODS This is a retrospective study of consecutive UC patients who underwent IPAA between 2011 and 2017, operated according to a modified 2- or 3-stage approach. Close rectal dissection was performed in Ta-IPAA as opposed to total mesorectal excision in Tabd-IPAA. A propensity score weighting was performed. Functional outcomes were assessed using the pouch functional score (PFS) and the Öresland score (OS). The global quality of life scale (GQOL) was used for patients' perspective on QoL. Follow-up was scheduled at 1, 3, 6, and 12 months, postoperatively. RESULTS One hundred and eight patients were included: 38 patients had Ta-IPAA. At 12 months follow-up, mean OS and PFS were 4.6 (CI 3.2-6.0) vs 6.2 (CI 5.0-7.3), p = 0.025 and 6.1 (CI 3.5-8.8) vs 7.4 (CI 5.4-9.5), p = 0.32, for Ta and Tabd-IPAA, respectively. Mean GQOL for Ta-IPAA was 82.5 (CI 74.8-90.1) vs 75.5 (69.4-81.7) for Tabd-IPAA (p = 0.045). CONCLUSIONS At 12 months postoperatively, pouch function and QoL of Ta-IPAA are probably as good as those of Tabd-IPAA. Limitations include retrospectivity, differences in the surgical technique, and lack of validated scores for QoL.
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Abstract
AbstractCrohn's disease (CD) is a chronic relapsing inflammatory bowel disease with unknown etiology. Up to 80% of patients will eventually require surgery throughout their lifetime, and often repeated resections are required for disease recurrence. Observations of “creeping fat” surrounding the diseased intestine renewed interest in the mesentery, recently defined as an organ with endocrine and immune functions. According to the inside-out model, the mesentery may be primarily affected in CD and subsequent cause alterations in the mucosa. Recently, lower surgical recurrence rates have been reported with en-bloc excision of the mesentery adjoining the diseased intestine. Results of ongoing randomized controlled trials may clarify the role of the mesentery in CD and possibly lead to its adoption as standard during surgery for Crohn's disease.
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Fuschillo G, Pellino G. Chronic Perineal Sinus After Proctectomy for Crohn's Disease: Risk Reduction Strategies and Management. Dis Colon Rectum 2022; 65:468-471. [PMID: 35067504 DOI: 10.1097/dcr.0000000000002413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Giacomo Fuschillo
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli," Naples, Italy
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Has the Removing of the Mesentery during Ileo-Colic Resection an Impact on Post-Operative Complications and Recurrence in Crohn’s Disease? Results from the Resection of the Mesentery Study (Remedy). J Clin Med 2022; 11:jcm11071961. [PMID: 35407568 PMCID: PMC8999639 DOI: 10.3390/jcm11071961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/17/2022] [Accepted: 03/22/2022] [Indexed: 02/04/2023] Open
Abstract
Some evidence suggests a reduction in clinical and surgical recurrence after mesenteric resection in Crohn’s Disease (CD). The aim of the REsection of the MEsentery StuDY (Remedy) was to assess whether mesenteric removal during surgery for ileocolic CD has an impact in terms of postoperative complications, endoscopic and ultrasonographic recurrences, and long-term surgical recurrence. Among the 326 patients undergoing primary resection between 2009 and 2019 in two referral centers, in 204 (62%) the mesentery was resected (Group A) and in 122 (38%) it was retained (Group B). Median follow-up was 4.7 ± 3 years. Groups were similar in the peri-operative course. Endoscopic and ultrasonographic recurrences were 44.6% and 40.4% in Group A, and 46.7% and 41.2% in Group B, respectively, without statistically significant differences. The five-year time-to-event estimates, compared with the Log-rank test, were 3% and 4% for normal or thickened mesentery (p = 0.6), 2.8% and 4% for resection or sparing of the mesentery (p = 0.6), and 1.7% and 5.4% in patients treated with biological or immunosuppressants versus other adjuvant therapy (p = 0.02). In Cox’s model, perforating behavior was a risk factor, and biological or immunosuppressant adjuvant therapy protective for surgical recurrence. The resection of the mesentery does not seem to reduce endoscopic and ultrasonographic recurrences, and the five-year recurrence rate.
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Danilov MA, Leontiev AV, Abdulatipova ZM, Demidova AA. [Strictureplasty or resection? Optimal approach for fibrostenotic Crohn's disease]. Khirurgiia (Mosk) 2022:100-103. [PMID: 35147008 DOI: 10.17116/hirurgia2022021100] [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: 11/17/2022]
Abstract
The indications for surgical intervention in patients with Crohn's disease (CD) are ineffective therapy and complications of this disease. In case of fibrostenotic CD, strictureplasty or bowel resection are indicated. The indications for organ-sparing surgeries are multiple small bowel lesions, previous surgery for CD and short bowel syndrome. Strictureplasty is not advisable in patients with fistulas, abscesses, bowel perforation and severe hypoalbuminemia due to extremely high risk of anastomotic leakage. Therefore, bowel resection is recommended if strict indications for various types of strictureplasty are absent. This approach is associated with effective maintenance of remission and longer recurrence-free period.
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Affiliation(s)
- M A Danilov
- Loginov Moscow Clinical Scientific Center, Russia, Moscow
| | - A V Leontiev
- Loginov Moscow Clinical Scientific Center, Russia, Moscow
| | | | - A A Demidova
- Loginov Moscow Clinical Scientific Center, Russia, Moscow
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van der Does de Willebois EML. Mesenteric SParIng versus extensive mesentereCtomY in primary ileocolic resection for ileocaecal Crohn's disease (SPICY): study protocol for randomized controlled trial. BJS Open 2022; 6:6529311. [PMID: 35171266 PMCID: PMC8848735 DOI: 10.1093/bjsopen/zrab136] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/26/2021] [Indexed: 01/10/2023] Open
Abstract
Background There is emerging evidence to suggest that Crohn’s disease (CD) may be a disease of the mesentery, rather than of the bowel alone. A more extensive mesenteric resection, removing an increased volume of mesentery and lymph nodes to prevent recurrence of CD, may improve clinical outcomes. This study aims to analyse whether more extensive ‘oncological’ mesenteric resection reduces the recurrence rate of CD. Methods This is an international multicentre randomized controlled study, allocating patients to either group 1—mesenteric sparing ileocolic resection (ICR), the current standard procedure for CD, or group 2—extensive mesenteric ICR, up to the level of the ileocolic trunk. To detect a clinically relevant difference of 25 per cent in endoscopic recurrence at 6 months, a total of 138 patients is required (including 10 per cent dropout). Patients aged over 16 with CD undergoing primary ICR are eligible. Primary outcome is 6-month postoperative endoscopic recurrence rate (modified Rutgeerts score of greater than or equal to i2b). Secondary outcomes are postoperative morbidity, clinical recurrence, quality of life, and the need for (re)starting immunosuppressive medication. For long-term results, patients will be followed up for up to 5 years to determine the reoperation rate for recurrence of disease at the anastomotic site. Conclusion Analysing these two treatment strategies in a head-to-head comparison will allow an objective evaluation of the clinical relevance of extensive mesenteric resection in CD. If a clinical benefit can be demonstrated, this could result in changes to guidelines which currently recommend close bowel resection. Registration number NCT00287612 (http://www.clinicaltrials.gov)
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Holubar SD, Gunter RL, Click BH, Achkar JP, Lightner AL, Lipman JM, Hull TL, Regueiro M, Rieder F, Steele SR. Mesenteric Excision and Exclusion for Ileocolic Crohn's Disease: Feasibility and Safety of an Innovative, Combined Surgical Approach With Extended Mesenteric Excision and Kono-S Anastomosis. Dis Colon Rectum 2022; 65:e5-e13. [PMID: 34882636 PMCID: PMC9148419 DOI: 10.1097/dcr.0000000000002287] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Ileocolic resection for Crohn's disease traditionally does not include a high ligation of the ileocolic pedicle, and most commonly is performed with a stapled side-to-side ileocolic anastomosis. The mesentery has recently been implicated in the pathophysiology of Crohn's disease. Two techniques have been developed and are associated with reduced postoperative recurrence: the Kono-S anastomosis that excludes diseased mesentery and extended mesenteric excision that resects diseased mesentery. We aimed to assess the technical feasibility and safety of a novel combination of techniques: mesenteric excision and exclusion. TECHNIQUES This initial report is a single-center descriptive study of consecutive adults who underwent mesenteric excision and exclusion for primary or recurrent ileocolic Crohn's disease from September 2020 to June 2021. Medication exposure and endoscopic balloon dilation before surgery were recorded. Phenotype was classified using the Montreal Classification. Thirty-day outcomes were reported. A video of the mesenteric excision and exclusion including the Kono-S anastomosis is presented. RESULTS Twenty-two patients with ileocolic Crohn's disease underwent mesenteric excision and exclusion: 100% had strictures, 59% had fistulas, 81% were on biologics, and 27% had previous ileocolic resection(s). Seventy-two percent underwent laparoscopic procedures, a mesenteric defect was closed in 86%, omental flaps were fashioned in 77%, and 3 patients were diverted. Median operative time was 175 minutes. Median postoperative stay was 4 days. At 30 days, there were 2 readmissions for reintervention: 1 seton placement and 1 percutaneous drainage of a sterile collection. There were no cases of intra-abdominal sepsis or anastomotic leak. CONCLUSIONS Mesenteric excision and exclusion represents an innovative, progressive, and promising approach that appears to be highly feasible and safe. Further study is warranted to determine if mesenteric excision and exclusion is associated with reduced postoperative recurrence of ileocolic Crohn's disease.
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Affiliation(s)
- Stefan D. Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Rebecca L. Gunter
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Benjamin H. Click
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Jean-Paul Achkar
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Amy L. Lightner
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Jeremy M. Lipman
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Tracy L. Hull
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Scott R. Steele
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
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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: 0] [Impact Index Per Article: 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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Brar MS, de Buck van Overstraeten A, Baxter NN. Rectal Cancer Incidence is Low Following Rectal Diversion or Subtotal Colectomy for IBD: Results of a Population-based Study. J Crohns Colitis 2021; 15:1787-1798. [PMID: 34165532 DOI: 10.1093/ecco-jcc/jjab090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Following subtotal colectomy or diversion for medically refractory inflammatory bowel disease [IBD], completion proctectomy has been recommended to reduce the risk of rectal cancer. However, this recommendation is based on low-quality evidence. Our objectives were to estimate the cumulative incidence of rectal cancer and evaluate if surveillance endoscopy reduces the risk of rectal cancer. METHODS We performed a population-based retrospective cohort study in Ontario, Canada, of all patients undergoing either subtotal colectomy or diversion for medically refractory IBD over 1991-2015. We excluded patients with a previous history of colorectal cancer or previous rectal resection, and those with <1 year of observation. We calculated the rate of incident rectal cancer using a competing risks model, and evaluated the effect of surveillance endoscopy on the rate of rectal cancer. RESULTS In all, 3700 patients were included with a median follow-up of 4.3 years. Of this cohort, 47% underwent rectal resection or restoration of gastrointestinal [GI] continuity during the observation period; 40 patients were diagnosed with rectal cancer, with a cumulative incidence of rectal cancer of 0.81% (95% confidence interval [CI] 0.53%, 1.20%) and 1.86% [95% CI 1.29%, 2.61%] at 10 and 20 years, respectively. Surveillance endoscopy was associated with a lower rate of rectal cancer (subhazard ratio [sHR] 0.37, 95% CI 0.16, 0.82, p = 0.014]. CONCLUSIONS Among patients with a retained rectum following surgery for IBD, the risk of rectal cancer is low and appears to be lower when surveillance endoscopy is performed. Expectant management with surveillance endoscopy may be a reasonable alternative to completion proctectomy in selected patients.
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Affiliation(s)
- Mantaj S Brar
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Anthony de Buck van Overstraeten
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| | - Nancy N Baxter
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.,Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
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Zhu Y, Qian W, Huang L, Xu Y, Guo Z, Cao L, Gong J, Coffey JC, Shen B, Li Y, Zhu W. Role of Extended Mesenteric Excision in Postoperative Recurrence of Crohn's Colitis: A Single-Center Study. Clin Transl Gastroenterol 2021; 12:e00407. [PMID: 34597277 PMCID: PMC8483874 DOI: 10.14309/ctg.0000000000000407] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 08/10/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The mesentery is involved in Crohn's disease. The impact of the extent of mesenteric resection on postoperative disease progression in Crohn's disease remains unconfirmed. This study aimed to determine the association between resection of the mesentery and postoperative outcomes in patients with Crohn's colitis (CC) undergoing colorectal surgery. METHODS Patients with CC who underwent colorectal resection between January 2000 and December 2018 were reviewed, and the data were gathered from a prospectively maintained database. Patients were divided into 2 groups according to the extent of mesenteric resection, the extensive mesenteric excision (EME) group and the limited mesenteric excision (LME) group. Outcomes including early postoperative morbidities and surgical recurrence were compared between the 2 groups. RESULTS Of the 126 patients included, 60 were in the LME group and 66 in the EME group. There was no significant difference between the 2 groups in early postsurgical outcomes except the intraoperative blood loss was increased in the LME group (P = 0.002). Patients in the EME group had a longer postoperative surgical recurrence-free survival time when compared with those in the LME group (P = 0.01). LME was an independent predictor of postoperative surgical recurrence (hazard ratio 2.67, 95% confidence interval 1.04-6.85, P = 0.04). This was further confirmed in the subgroup analysis of patients undergoing colorectal resection and anastomosis (hazard ratio 2.83, 95% confidence interval 1.01-7.96, P = 0.048). DISCUSSION In patients undergoing surgery for CC, inclusion of the mesentery is associated with similar short-term outcomes and improved long-term outcomes compared with those seen when the mesentery is retained.
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Affiliation(s)
- Yipeng Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Southeast University, Nanjing, PR China;
| | - Wenwei Qian
- Department of General Surgery, Jinling Hospital, Medical School of Southeast University, Nanjing, PR China;
| | - Liangyu Huang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China;
| | - Yihan Xu
- Department of General Surgery, Jinling Hospital, School of Nanjing Medical University, Nanjing, PR China;
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China;
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China;
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China;
| | - J. Calvin Coffey
- Department of Surgery, University Hospital Limerick, Limerick, Ireland
| | - Bo Shen
- Section of Inflammatory Bowel Diseases and Center for Interventional IBD, Columbia University Irving Medical Center-New York Presbyterian, New York, New York, USA
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Medical School of Southeast University, Nanjing, PR China;
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China;
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Southeast University, Nanjing, PR China;
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China;
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Springer JE, Guber RD, Davids JS, Sturrock PR, Alavi K, Maykel JA. Total Transperineal Laparoscopic Proctectomy for the Treatment of Crohn's Proctitis. Dis Colon Rectum 2021; 64:e584-e587. [PMID: 34285146 DOI: 10.1097/dcr.0000000000002040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Completion proctectomy is traditionally performed using a combination of abdominal and perineal approaches. Access to and exposure of the pelvis through the abdominal cavity can be limited in patients with prior surgery or inflammatory conditions. We describe a novel technique for a total transperineal approach for proctectomy for Crohn's proctitis, avoiding technical challenges, risks, and recovery associated with abdominal surgery. TECHNIQUE We utilized the skills and expertise acquired from our experience with transanal total mesorectal excision to perform a total transperineal laparoscopic proctectomy in a male patient with medically refractory proctitis. He previously underwent an anterior resection, drainage of a chronic presacral abscess, omental pedicle flap transposition to the pelvis, and end colostomy for severe Crohn's colitis. The total transperineal laparoscopic proctectomy approach avoids the need for abdominal access, including the risks associated with abdominal entry, adhesiolysis, pelvic access and visualization, and wound-related issues. Following an initial intersphincteric perineal dissection, the GelPOINT Path minimal access platform is utilized to perform a total transperineal proctectomy. RESULTS The patient recovered uneventfully and was discharged to home 2 days after surgery. At 1-month postoperative follow-up, the patient is recovering well with complete healing of the perineal wound. CONCLUSION We demonstrate the feasibility, safety, and technical steps of a minimally invasive completion proctectomy for fistulizing Crohn's proctitis by using a total transperineal approach. This approach allowed us to utilize direct, inline, high-definition visualization to access and safely operate in the distal aspects of a narrow, scarred, and fibrotic pelvis while avoiding the need for any abdominal access. Advanced experience with redo pelvic and minimally invasive transanal surgery is critical. See Video at http://links.lww.com/DCR/B664.
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Affiliation(s)
- Jeremy E Springer
- Department of Surgery, Division of Colorectal Surgery, University of Massachusetts, Worcester, Massachusetts
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Grant RK, Elosua-González A, Bouri S, Sahnan K, Brindle WM, Dilke SM, Vincent MLM, Adegbola SOA, Warusavitarne JH, Tozer PJ, Arnott IDR, Hart AL. Prognostic factors associated with unhealed perineal wounds post-proctectomy for perianal Crohn's disease: a two-centre study. Colorectal Dis 2021; 23:2091-2099. [PMID: 34021522 DOI: 10.1111/codi.15744] [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: 12/18/2020] [Revised: 03/11/2021] [Accepted: 05/13/2021] [Indexed: 12/19/2022]
Abstract
AIM The aim of this work was to determine the factors associated with poor wound healing in patients with perianal Crohn's disease (pCD) who had undergone proctectomy in the era of biologic therapies. METHOD Case record review was performed on 103 patients with pCD who underwent proctectomy at St Mark's Hospital, Harrow and the Western General Hospital, Edinburgh between 2005 and 2017. Healing rates at 6 and 12 months post-proctectomy were considered; univariate analysis was performed. RESULTS Sixty out of 103 patients (58.3%) had failure of wound healing at 6 months and 41/103 (39.8%) at 12 months. In total, 63.1% (65/103) patients received biologic therapies prior to proctectomy; however, exposure to biologics was not a significant factor in predicting failure of wound healing at 12 months (infliximab p = 0.255; adalimumab p = 0.889; vedolizumab p = 0.153). Male gender was the only variable associated with poor wound healing at 12 months on univariate analysis (p = 0.017). A lower pre-operative C-reactive protein was associated with early wound healing at 6 months compared with at 12 months (p = 0.041) on univariate analysis. Other parameters not associated with rates of wound healing included smoking status, corticosteroid exposure, thiopurine exposure, number of previous biologics, perianal sepsis on MRI within the last 12 months, duration of CD prior to proctectomy and pre-operative albumin. CONCLUSION More than a third of patients had unhealed wounds 12 months after proctectomy. We report that unhealed wounds are more common in male patients. Importantly, our results also suggest that exposure to biologics does not affect rates of wound healing.
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Affiliation(s)
- Rebecca K Grant
- The Edinburgh IBD Unit, Western General Hospital, Edinburgh, UK
| | | | | | | | | | | | | | | | | | | | - Ian D R Arnott
- The Edinburgh IBD Unit, Western General Hospital, Edinburgh, UK
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15
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Abstract
INTRODUCTION: Clinical trials are currently investigating whether an extended mesenteric
resection for ileocecal resections could reduce postoperative recurrence in
Crohn's disease. Resection of the mesorectum, which contains
proinflammatory macrophages, during proct(ocol)ectomy, is associated with
reduced recurrent inflammation and improved wound healing. We aimed to
characterize the macrophages in the ileocecal mesentery, which were compared
with those in the mesorectum, to provide a biological rationale for the
ongoing trials. METHODS: In 13 patients with Crohn's disease and 4 control patients undergoing a
proctectomy, tissue specimens were sampled at 3 locations from the
mesorectum: distal (rectum), middle, and proximal (sigmoid). In 38 patients
with Crohn's disease and 7 control patients undergoing ileocecal
resections, tissue specimens also obtained from 3 locations: adjacent to the
inflamed terminal ileum, adjacent to the noninflamed ileal resection margin,
and centrally along the ileocolic artery. Immune cells from these tissue
specimens were analyzed by flow cytometry for expression of CD206 to
determine their inflammatory status. RESULTS: In the mesorectum, a gradient from proinflammatory to regulatory macrophages
from distal to proximal was observed, corresponding to the adjacent
inflammation of the intestine. By contrast, the ileocecal mesentery did not
contain high amounts of proinflammatory macrophages adjacent to the inflamed
tissue, and a gradient toward a more proinflammatory phenotype was seen in
the central mesenteric area. DISCUSSION: Although the mesentery is a continuous structure, the mesorectum and the
ileocecal mesentery show different immunological characteristics. Therefore,
currently, there is no basis to perform an extended ileocecal resection in
patients with Crohn's disease.
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16
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Adamina M, Feakins R, Iacucci M, Spinelli A, Cannatelli R, D'Hoore A, Driessen A, Katsanos K, Mookhoek A, Myrelid P, Pellino G, Peros G, Tontini GE, Tripathi M, Yanai H, Svrcek M. ECCO Topical Review Optimising Reporting in Surgery, Endoscopy, and Histopathology. J Crohns Colitis 2021; 15:1089-1105. [PMID: 33428711 DOI: 10.1093/ecco-jcc/jjab011] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Diagnosis and management of inflammatory bowel diseases [IBD] requires a lifelong multidisciplinary approach. The quality of medical reporting is crucial in this context. The present topical review addresses the need for optimised reporting in endoscopy, surgery, and histopathology. METHODS A consensus expert panel consisting of gastroenterologists, surgeons, and pathologists, convened by the European Crohn's and Colitis Organisation, performed a systematic literature review. The following topics were covered: in endoscopy: [i] general IBD endoscopy; [ii] disease activity and surveillance; [iii] endoscopy treatment in IBD; in surgery: [iv] medical history with surgical relevance, surgical indication, and strategy; [v] operative approach; [vi] intraoperative disease description; [vii] operative steps; in pathology: [viii] macroscopic assessment and interpretation of resection specimens; [ix] IBD histology, including biopsies, surgical resections, and neoplasia; [x] IBD histology conclusion and report. Statements were developed using a Delphi methodology incorporating two consecutive rounds. Current practice positions were set when ≥ 80% of participants agreed on a recommendation. RESULTS Thirty practice positions established a standard terminology for optimal reporting in endoscopy, surgery, and histopathology. Assessment of disease activity, surveillance recommendations, advice to surgeons for operative indication and strategies, including margins and extent of resection, and diagnostic criteria of IBD, as well as guidance for the interpretation of dysplasia and cancer, were handled. A standardised report including a core set of items to include in each specialty report, was defined. CONCLUSIONS Interdisciplinary high-quality care requires thorough and standardised reporting across specialties. This topical review offers an actionable framework and practice recommendations to optimise reporting in endoscopy, surgery, and histopathology.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Roger Feakins
- Department of Cellular Pathology, Royal Free Hospital, London, UK
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, NIHR Biomedical Research Centre, University of Birmingham, UK.,Division of Gastroenterology, University Hospitals Birmingham NHS Trust, UK
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano,Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Rosanna Cannatelli
- Institute of Translational Medicine, University of Birmingham, Birmingham, UK.,Gastroenterology Unit, Spedali Civili di Brescia, Brescia, Italy
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - Ann Driessen
- Department of Pathology, University Hospital Antwerp, University Antwerp, Edegem, Belgium
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Aart Mookhoek
- Department of Pathology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Pär Myrelid
- Department of Surgery, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy.,Colorectal Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Georgios Peros
- Department of Surgery, Cantonal Hospital of Winterthur, Winterthur, Switerland; Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Gian Eugenio Tontini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Monika Tripathi
- Department of Histopathology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Henit Yanai
- Division of Gastroenterology, IBD Center, Rabin Medical Center, Petah Tikva, Israel
| | - Magali Svrcek
- Department of Pathology, Sorbonne Université, AP-HP, Saint-Antoine hospital, Paris, France
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17
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Post-surgical recurrence of Crohn's disease: Situational analysis and future prospects. J Visc Surg 2021; 158:401-410. [PMID: 33858790 DOI: 10.1016/j.jviscsurg.2021.03.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Surgery retains a major role in the treatment of Crohn's disease, and the prevention of post-operative recurrence is an essential issue. In fact, despite the increasing use of biotherapies, almost all of the patients who undergo surgery will present with a recurrence, initially endoscopic and then clinical, eventually leading to a second intervention in 15 to 20% of cases. Certain risk factors for recurrence such as smoking, repeated and/or extensive resections, anoperineal involvement, myenteric plexitis, epithelioid granulomas, penetrating disease behaviour and lack of post-operative prophylactic treatment have been well established. Currently, measures to prevent post-operative recurrence are based mainly on smoking cessation in all patients and the prescription of anti-TNFα medications for patients with a high risk of recurrence (at least two risk factors for recurrence). However, new surgical techniques have recently been described which could modify post-operative prevention strategies. Kono's lateral anti-mesenteric anastomosis could significantly reduce clinical and endoscopic recurrence compared to conventional anastomosis techniques. Long latero-lateral isoperistaltic stricturoplasties have been shown to be feasible and are associated with a low rate of long-term symptomatic recurrence requiring surgery. In a preliminary series, intestinal resections with extensive mesenteric resection reduced the rate of recurrence in comparison with patients operated on conventionally (3% vs. 40% at five years). If the results of these new surgical techniques are confirmed, the indications for post-operative immunomodulatory treatments could be downgraded in patients currently considered to be at high risk of recurrence.
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18
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van der Does de Willebois EML, Buskens CJ, Bemelman WA. Technical standardization of laparoscopic extended mesenterectomy in ileocolic resection in Crohn's disease - a video vignette. Colorectal Dis 2021; 23:1015-1016. [PMID: 33503309 DOI: 10.1111/codi.15546] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/03/2020] [Accepted: 12/29/2020] [Indexed: 02/08/2023]
Affiliation(s)
| | | | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
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19
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Alshantti A, Hind D, Hancock L, Brown SR. The role of Kono-S anastomosis and mesenteric resection in reducing recurrence after surgery for Crohn's disease: a systematic review. Colorectal Dis 2021; 23:7-17. [PMID: 32418300 DOI: 10.1111/codi.15136] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 04/18/2020] [Indexed: 02/08/2023]
Abstract
AIM Recurrence after surgery for Crohn's disease is common. Anastomotic configuration may influence recurrence and the mesentery may be key. Recently the Kono-S anastomosis and radical mesenteric excision have been proposed as methods of reducing recurrence. We analysed the literature pertaining to these novel techniques. METHOD We searched MEDLINE, Embase and the Cochrane Library for, and selected, studies evaluating Kono-S anastomosis and/or radical mesenteric excision in Crohn's disease. We assessed methodological quality and risk of bias using the Cochrane risk of bias tool for randomized controlled trials and the Joanna Briggs Institute tool for nonrandomized trials. A narrative synthesis was used to summarize the findings. RESULTS Nine studies (896 patients) were identified. Apart from one randomized controlled trial with a low risk of bias the overall level of evidence was poor (Grade IV). The Kono-S anastomosis was associated with a lower incidence of endoscopic and surgical recurrence (0%-3.4% vs 15%-24.4% respectively). Complications, particularly anastomotic leak rate, were also lower (1.8% vs 9.3% respectively). Evidence from a single poor quality study suggested that mesenteric excision may reduce surgical recurrence rates compared with mesentery preservation. CONCLUSION The existing literature suggests that the Kono-S anastomosis is safe and may reduce endoscopic and surgical recurrence, but level of evidence is mainly poor. One element of the Kono-S technique, preservation of the mesentery, may be detrimental to recurrence. Further, higher quality, studies are required to investigate these techniques. Such studies should consider the impact of the degree of mesenteric resection in addition to the anastomosis on disease recurrence.
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Affiliation(s)
| | - D Hind
- University of Sheffield, Sheffield, UK
| | - L Hancock
- Manchester University NHS Trust, Manchester, UK
| | - S R Brown
- University of Sheffield, Sheffield, UK
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20
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Abstract
PURPOSE The aim of this review was to examine current surgical treatments in patients with Crohn's disease (CD) and to discuss currently popular research questions. METHODS A literature search of MEDLINE (PubMed) was conducted using the following search terms: 'Surgery' and 'Crohn'. Different current surgical treatment strategies are discussed based on disease location. RESULTS Several surgical options are possible in medically refractory or complex Crohn's disease as a last resort therapy. Recent evidence indicated that surgery could also be a good alternative in terms of effectiveness, quality of life and costs as first-line therapy if biologicals are considered, e.g. ileocolic resection for limited disease, or as part of combination therapy with biologicals, e.g. surgery aiming at closure of select perianal fistula in combination with biologicals. The role of the mesentery in ileocolic disease and Crohn's proctitis is an important surgical dilemma. In proctectomy, evidence is directing at removing the mesentery, and in ileocolic disease, it is still under investigation. Other surgical dilemmas are the role of the Kono-S anastomosis as a preventive measure for recurrent Crohn's disease and the importance of (non)conventional stricturoplasties. CONCLUSION Surgical management of Crohn's disease remains challenging and is dependent on disease location and severity. Indication and timing of surgery should always be discussed in a multidisciplinary team. It seems that early surgery is gradually going to play a more important role in the multidisciplinary management of Crohn's disease rather than being a last resort therapy.
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21
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Slooter MD, Blok RD, de Krom MA, Buskens CJ, Bemelman WA, Tanis PJ, Hompes R. Optimizing omentoplasty for management of chronic pelvic sepsis by intra-operative fluorescence angiography: a comparative cohort study. Colorectal Dis 2020; 22:2252-2259. [PMID: 32683788 PMCID: PMC7818129 DOI: 10.1111/codi.15276] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/09/2020] [Indexed: 12/17/2022]
Abstract
AIM Pelviperineal wound complications frequently occur after salvage surgery for chronic pelvic sepsis despite using an omentoplasty. Sufficient perfusion of the omentoplasty following mobilization is essential for proper healing. This study investigated the impact on short-term clinical outcomes of fluorescence angiography (FA) using indocyanine green for assessment of omental perfusion in patients undergoing salvage surgery. METHOD This was a comparative cohort study including consecutive patients who underwent combined abdominal and transanal minimally invasive salvage surgery with omentoplasty at a national referral centre for chronic pelvic sepsis between December 2014 and August 2019. The historical and interventional cohorts were defined based on the date of introduction of FA in April 2018. The primary outcome was pelviperineal non-healing, defined by the presence of any degree of pelviperineal infection at the final postoperative evaluation. RESULTS Eighty-eight patients underwent salvage surgery with omentoplasty for chronic pelvic sepsis, of whom 52 did not have FA and 36 did have FA. The underlying primary disease was Crohn's disease (n = 50) or rectal cancer (n = 38), with even distribution among the cohorts (P = 0.811). FA led to a change in management in 28/36 (78%) patients. After a median of 89 days, pelviperineal non-healing was observed in 22/52 (42%) patients in the cohort without FA and in 8/36 (22%) patients in the cohort with FA (P = 0.051). Omental necrosis was found during reoperation in 3/52 and 0/36 patients, respectively (P = 0.266). CONCLUSION After introduction of FA to assess perfusion of the omentoplasty, halving of the pelviperineal non-healing rate was observed in patients undergoing salvage surgery for chronic pelvic sepsis.
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Affiliation(s)
- M. D. Slooter
- Department of SurgeryCancer Centre AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - R. D. Blok
- Department of SurgeryCancer Centre AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands,LEXORCentre for Experimental and Molecular MedicineOncode InstituteCancer Centre AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - M. A. de Krom
- Department of SurgeryCancer Centre AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - C. J. Buskens
- Department of SurgeryCancer Centre AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - W. A. Bemelman
- Department of SurgeryCancer Centre AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - P. J. Tanis
- Department of SurgeryCancer Centre AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - R. Hompes
- Department of SurgeryCancer Centre AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
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22
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Zabot GP, Cassol O, Saad-Hossne R, Bemelman W. Modern surgical strategies for perianal Crohn's disease. World J Gastroenterol 2020; 26:6572-6581. [PMID: 33268947 PMCID: PMC7673971 DOI: 10.3748/wjg.v26.i42.6572] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/05/2020] [Accepted: 09/28/2020] [Indexed: 02/06/2023] Open
Abstract
One of the most challenging phenotypes of Crohn’s disease is perianal fistulizing disease (PFCD). It occurs in up to 50% of the patients who also have symptoms in other parts of the gastrointestinal tract, and in 5% of the cases it occurs as the first manifestation. It is associated with severe symptoms, such as pain, fecal incontinence, and a significant reduction in quality of life. The presence of perianal disease in conjunction with Crohn’s disease portends a significantly worse disease course. These patients require close monitoring to identify those at risk of worsening disease, suboptimal biological drug levels, and signs of developing neoplasm. The last 2 decades have seen significant advancements in the management of PFCD. More recently, newer biologics, cell-based therapies, and novel surgical techniques have been introduced in the hope of improved outcomes. However, in refractory cases, many patients face the decision of having a stoma made and/or a proctectomy performed. In this review, we describe modern surgical management and the most recent advances in the management of complex PFCD, which will likely impact clinical practice.
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Affiliation(s)
- Gilmara Pandolfo Zabot
- Department of Coloproctology, Hospital Moinhos de Vento, Porto Alegre 90035-902, RS, Brazil
| | - Ornella Cassol
- Department of Surgery, Hospital de Clínicas de Passo Fundo, Passo Fundo 99010-260, RS, Brazil
| | - Rogerio Saad-Hossne
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu 18618687, São Paulo, Brazil
| | - Willem Bemelman
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam 19268, Netherlands
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23
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Liu R, Qiao S, Shen W, Liu Y, Lu Y, Liangyu H, Guo Z, Gong J, Shui G, Li Y, Zhu W. Disturbance of Fatty Acid Desaturation Mediated by FADS2 in Mesenteric Adipocytes Contributes to Chronic Inflammation of Crohn's Disease. J Crohns Colitis 2020; 14:1581-1599. [PMID: 32365195 DOI: 10.1093/ecco-jcc/jjaa086] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS The aim of this study was to investigate the metabolic profile of mesenteric adipocytes and the correlations between key metabolic changes and local inflammation in the context of Crohn's disease [CD]. METHODS Metabolic dysfunction was shown to be regulated by fatty acid desaturase-2 [FADS2], through metabolomics and functional analyses of mesenteric adipose tissue biopsies and primary mesenteric adipocytes isolated from surgical specimens collected from CD patients and control subjects. FADS2 was overexpressed in vitro and in vivo using a lentiviral vector and an adeno-associated virus [AAV], respectively. The interaction between mesenteric adipocytes and inflammation responses was evaluated by establishing a cell coculture system and a FADS2-AAV treated animal model; 3T3-L1 cells were used to elucidate the mechanism underlying FADS2 deregulation. RESULTS We observed significant changes in the levels of metabolites involved in the multi-step synthesis of long-chain polyunsaturated fatty acids [PUFAs]. Gas chromatography analysis revealed impaired desaturation fluxes towards the n-6 and n-3 pathways, which are associated with reduced FADS2 activity in human mesentery tissue. Decreased FADS2 expression at both mRNA and protein levels was confirmed in surgical specimens. The restoration of FADS2 expression, which allows for the endogenous conversion of n-3 fatty acids into proresolving lipid mediators, resulted in a significant reduction in pro-inflammatory macrophage infiltration and attenuated expression of inflammatory cytokines or adipokines. CONCLUSIONS These findings indicate that impaired fatty acid desaturation and lipid mediator imbalance within mesenteric adipose tissue contributes to chronic inflammation in CD. The therapeutic role of FADS2 may lead to improved CD treatment.
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Affiliation(s)
- Ruiqing Liu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shuaihua Qiao
- Department of Cardiology, Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Weisong Shen
- Department of Gastroenterological Surgery, Peking University People's Hospital, Peking, China
| | - Yue Liu
- State Key Laboratory of Pharmaceutical Biotechnology and Nanjing Drum Tower Hospital, Model Animal Research Center, Nanjing University, Nanjing, China
| | - Yun Lu
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Huang Liangyu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Guanghou Shui
- State Key Laboratory of Molecular Developmental Biology, Institute of Genetics and Developmental Biology, University of Chinese Academy of Sciences, Beijing, China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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24
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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: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [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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25
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Mesentery - a 'New' organ. Emerg Top Life Sci 2020; 4:191-206. [PMID: 32539112 DOI: 10.1042/etls20200006] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 12/13/2022]
Abstract
The mesentery is the organ in which all abdominal digestive organs develop, and which maintains these in systemic continuity in adulthood. Interest in the mesentery was rekindled by advancements of Heald and Hohenberger in colorectal surgery. Conventional descriptions hold there are multiple mesenteries centrally connected to the posterior midline. Recent advances first demonstrated that, distal to the duodenojejunal flexure, the mesentery is a continuous collection of tissues. This observation explained how the small and large intestines are centrally connected, and the anatomy of the associated peritoneal landscape. In turn it prompted recategorisation of the mesentery as an organ. Subsequent work demonstrated the mesentery remains continuous throughout development, and that abdominal digestive organs (i.e. liver, spleen, intestine and pancreas) develop either on, or in it. This relationship is retained into adulthood when abdominal digestive organs are directly connected to the mesentery (i.e. they are 'mesenteric' in embryological origin and anatomical position). Recognition of mesenteric continuity identified the mesenteric model of abdominal anatomy according to which all abdominal abdomino-pelvic organs are organised into either a mesenteric or a non-mesenteric domain. This model explains the positional anatomy of all abdominal digestive organs, and associated vasculature. Moreover, it explains the peritoneal landscape and enables differentiation of peritoneum from the mesentery. Increased scientific focus on the mesentery has identified multiple vital or specialised functions. These vary across time and in anatomical location. The following review demonstrates how recent advances related to the mesentery are re-orientating the study of human biology in general and, by extension, clinical practice.
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26
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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: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Brown SR, Lee MJ. Preservation of the Mesorectum in Proctectomy for Crohn's Disease Does Not Compromise Outcome. J Crohns Colitis 2020; 14:1030. [PMID: 31971999 DOI: 10.1093/ecco-jcc/jjaa013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Steven R Brown
- Department of Surgery, Sheffield Teaching Hospitals, Sheffield, UK
| | - Matthew J Lee
- Department of Surgery, Sheffield Teaching Hospitals, Sheffield, UK
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Lansdorp CA, Buskens CJ, Gecse KB, D'Haens GR, Van Hulst RA. Wound healing of metastatic perineal Crohn's disease using hyperbaric oxygen therapy: A case series. United European Gastroenterol J 2020; 8:820-827. [PMID: 32529922 PMCID: PMC7435003 DOI: 10.1177/2050640620934915] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Metastatic Crohn’s disease (CD) is a rare manifestation of CD. It involves inflammatory skin lesions with histopathological findings (granulomas) similar to CD, without connection to the gastrointestinal tract. Hyperbaric oxygen therapy (HBO) has been suggested as a possible treatment option. Objective This study aimed to identify and treat a consecutive series of patients with biopsy-proven metastatic CD and monitor wound healing using prospectively acquired outcomes. Methods Pathology results of all patients with ongoing perineal wound-healing problems after proctectomy between 2005 and 2018 at the Amsterdam University Medical Centre were assessed for metastatic CD. Patients with a biopsy-proven diagnosis of perineal metastatic CD were offered HBO (40 daily sessions of 100% oxygen at 2.4 atmosphere absolute). Wound healing was monitored using photographs and standardised questionnaires (the Inflammatory Bowel Disease Questionnaire, EuroQol Visual Analogue Scale and the Female Sexual Function Index) at baseline and 1 and 3 months after HBO. Results Out of 13 patients in the cohort with persisting perineal wounds after proctectomy, six (46%) had biopsy results consistent with metastatic CD. Of these, three accepted treatment with HBO. All three patients were female. One patient had complete healing of her perineal wound; another patient showed initial improvement but had a flare of luminal and perineal disease at the 3-month follow-up. The third patient showed improvement solely in the questionnaires, with higher scores on all three questionnaires. Conclusion A high rate of metastatic CD was found in patients with ongoing wound-healing problems after proctectomy, implying that the disease might not be as rare in these selected patients as previously thought. HBO might be beneficial in the treatment of metastatic CD.
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Affiliation(s)
- Corine A Lansdorp
- Department of Anaesthesiology/Hyperbaric Medicine, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands
| | - Christianne J Buskens
- Department of Surgery, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands
| | - Krisztina B Gecse
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands
| | - Geert Ram D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands
| | - Rob A Van Hulst
- Department of Anaesthesiology/Hyperbaric Medicine, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands
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Mohan H, Coffey J. Potential roles of the mesentery in Crohn's disease. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100743] [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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30
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Challenges in Crohn's disease: Complex perianal Crohn's disease. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Mohan HM, Coffey JC. Surgical treatment of intestinal stricture in inflammatory bowel disease. J Dig Dis 2020; 21:355-359. [PMID: 32410340 DOI: 10.1111/1751-2980.12880] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/03/2020] [Accepted: 05/12/2020] [Indexed: 12/11/2022]
Abstract
Fibroblast infiltration and collagen deposition result in structural changes in the bowel wall, and lead to strictures in intestinal inflammatory disease. While strictures can also occur in other contexts, such as malignancy, this review focuses on the surgical treatment of stricture secondary to inflammatory bowel disease. Distinguishing between predominantly inflammation vs established fibrosis as the cause of a stricture can be challenging. While inflammatory strictures may be responsive to medication, predominantly fibrotic strictures usually need surgical intervention. Both endoluminal and extraluminal approaches are described in this review. Endoscopic dilatation of strictures is suitable for short-segment isolated small bowel strictures. Other options are to divide the stricture surgically but preserve the length, performing a strictureplasty or resecting the strictured segment. The mesentery is increasingly recognized as playing a role in stricture recurrence. In a relapsing-remitting disease such as Crohn's disease, the preservation of intestinal length is essential and balance is needed between this and a complete resection to reduce the risk of recurrence. Pre- and postoperative involvement of the multidisciplinary team is essential to improve outcomes in this challenging clinical scenario.
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Affiliation(s)
- Helen M Mohan
- Department of Surgery, University Hospital Limerick, Limerick, Ireland
| | - John C Coffey
- Department of Surgery, University Hospital Limerick, Limerick, Ireland.,University of Limerick Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity, Limerick, Ireland
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Butt WT, Ryan ÉJ, Boland MR, McCarthy EM, Omorogbe J, Hazel K, Bass GA, Neary PC, Kavanagh DO, McNamara D, O'Riordan JM. Strictureplasty versus bowel resection for the surgical management of fibrostenotic Crohn's disease: a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:705-717. [PMID: 32048011 DOI: 10.1007/s00384-020-03507-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Strictureplasty (SPX) conserves bowel length and minimizes the risk of developing short bowel syndrome in patients undergoing surgery for Crohn's disease (CD). However, SPX may be associated with a higher risk of recurrence compared with bowel resection (BR). AIM We sought to compare morbidity and recurrence following SPX and BR in patients with fibrostenotic CD. METHODS A systematic review was performed according to PRISMA and MOOSE guidelines. Observational studies that compared outcomes of CD patients undergoing either SPX or BR were identified. Log hazard ratios (InHR) for recurrence-free survival (RFS) and their standard errors were calculated from Kaplan-Meier plots or Cox regression models and pooled using the inverse variance method. Dichotomous variables were pooled as odds ratios (OR) using the Mantel-Haenszel method. Continuous variables were pooled as weighted mean differences. RESULTS Twelve studies of 1026 CD patients (SPX n = 444, 43.27%; BR with or without SPX n = 582, 56.72%) were eligible for inclusion. There was an increased likelihood of disease recurrence with SPX than with BR (OR 1.61; 95% CI, 1.03, 2.52; p = 0.04; I2 = 0%). Patients who had a SPX alone had a significantly reduced RFS than those who underwent BR (HR 1.47; 95% CI, 1.08, 2.01; p = 0.02; I2 = 0%). There was no difference in morbidity between the groups (OR 0.58; 95% CI, 0.26, 1.28; p = 0.18; I2 = 0%). CONCLUSION SPX should only be performed in those patients with Crohn's strictures that are at high risk for short bowel syndrome and intestinal failure; otherwise, BR is the favored surgical technique for the management of fibrostenotic CD.
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Affiliation(s)
- Waqas T Butt
- Department of Surgery, Tallaght University Hospital, Tallaght, Dublin, D24 NR0A, Ireland.
| | - Éanna J Ryan
- Department of Surgery, Tallaght University Hospital, Tallaght, Dublin, D24 NR0A, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Michael R Boland
- Department of Surgery, Tallaght University Hospital, Tallaght, Dublin, D24 NR0A, Ireland
| | - Eilis M McCarthy
- Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland
| | - Joseph Omorogbe
- Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland
| | - Karl Hazel
- Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland
| | - Gary A Bass
- Department of Surgery, Tallaght University Hospital, Tallaght, Dublin, D24 NR0A, Ireland
| | - Paul C Neary
- Department of Surgery, Tallaght University Hospital, Tallaght, Dublin, D24 NR0A, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Dara O Kavanagh
- Department of Surgery, Tallaght University Hospital, Tallaght, Dublin, D24 NR0A, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Deirdre McNamara
- Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - James M O'Riordan
- Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
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Ryan ÉJ, Orsi G, Boland MR, Syed AZ, Creavin B, Kelly ME, Sheahan K, Neary PC, Kavanagh DO, McNamara D, Winter DC, O'Riordan JM. Meta-analysis of early bowel resection versus initial medical therapy in patient's with ileocolonic Crohn's disease. Int J Colorectal Dis 2020; 35:501-512. [PMID: 31915984 DOI: 10.1007/s00384-019-03479-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Early bowel resection (EBR) in ileocolonic Crohn's disease (CD) may be associated with more durable remission compared with initial medical therapy (IMT) even when biologic therapy is included. AIM To compare the efficacy of EBR versus IMT for ileocolonic CD METHODS: A systematic search was performed to identify studies that compared EBR (performed < 1 year from initial diagnosis) or IMT for the management of ileocolonic CD. Log hazard ratios (InHR) for relapse-free survival (RFS) and their standard errors were calculated from Kaplan-Meier plots and pooled using the inverse-variance method. Dichotomous variables were pooled as odds ratios (OR). Quality assessment of the included studies was performed using the Newcastle-Ottawa (NOS) and Jadad scales. RESULTS A total of 7 studies with 1863 CD patients (EBR n = 581, 31.2%; IMT n = 1282, 68.8%) were eligible for inclusion. There was a moderate-to-high risk of bias. The median NOS was 8 (range 7-9). There was a reduced likelihood of overall (OR, 0.53; 95% confidence interval (95% CI), 0.34, 0.83; p = 0.005) and surgical (OR, 0.47; 95% CI, 0.24, 0.91; p = 0.03) relapse with EBR. There was also a less requirement for maintenance biologic therapy (OR, 0.24; 95% CI, 0.14, 0.42; p < 0.0001). Patients who underwent EBR had a significantly improved RFS than those who underwent IMT (HR, 0.62; 95% CI, 0.52, 0.73; p < 0.001). There was no difference in morbidity (OR, 1.67; 95% CI, 0.44, 6.36; p = 0.45) between the groups. CONCLUSION EBR may be associated with less relapse and need for maintenance biologic therapy than IMT. 'Upfront' or early resection may represent a reasonable and cost-effective alternative to biologic therapy, especially in biologic-resistant subpopulations.
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Affiliation(s)
- Éanna J Ryan
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland. .,School of Medicine, University College Dublin, Dublin, Ireland.
| | - Gabriel Orsi
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland
| | - Michael R Boland
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland
| | - Adeel Zafar Syed
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland
| | - Ben Creavin
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Michael E Kelly
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Kieran Sheahan
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Histopathology, St. Vincent's University Hospital, Dublin, Ireland
| | - Paul C Neary
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland.,School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Dara O Kavanagh
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland.,School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Deirdre McNamara
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.,Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland
| | - Des C Winter
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - James M O'Riordan
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland.,School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
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Whole transcriptional analysis identifies markers of B, T and plasma cell signaling pathways in the mesenteric adipose tissue associated with Crohn's disease. J Transl Med 2020; 18:44. [PMID: 32000799 PMCID: PMC6993458 DOI: 10.1186/s12967-020-02220-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 01/10/2020] [Indexed: 12/21/2022] Open
Abstract
Background Crohn’s disease (CD) is a multifactorial disease characterized by chronic intestinal inflammation. The increased visceral adiposity near the affected intestinal area, of which mesenteric adipose tissue (MAT) is the main component, is a feature of CD. Both protective and pathological roles have been attributed to this disease-associated tissue in CD. To understand the contribution of MAT to CD pathophysiology, a molecular and cellular signature of disease-associated MAT in CD patients was provided. Methods We performed an observational study with whole transcriptional analysis by RNA sequencing (RNA-seq) of MAT and ileal mucosa from CD patients with active disease and controls. qPCR and immunohistology were performed for validation analysis. Results RNA-seq identified 17 significantly regulated genes (|FC| > 1.5; FDR < 0.05) in CD-MAT compared to non-IBD controls, with a marked upregulation of plasma cell genes (i.e., IGLL5, MZB1, CD79A, POU2AF1, FCRL5, JCHAIN, DERL3, SDC1, PIM2). A less strict statistical cutoff value (|FC| > 1.5, nominal p ≤ 0.05) yielded a larger list of 651 genes in CD-MAT compared to controls. CD ileum showed the significant regulation compared to control ileum of 849 genes (|FC| > 1.5; FDR < 0.05) or 2654 genes (|FC| > 1.5, nominal p ≤ 0.05). Ingenuity Pathway Analysis revealed the significant regulation of pathways related to T- and B cell functionality in the MAT of CD patients. Despite the differences between the MAT and ileal signatures of CD patients, we identified a subset of 204 genes significantly modulated in both tissues compared to controls. This common signature included genes related to the plasma cell signature. Genes such as S100A8, S100A9 (calprotectin) and IL1B, which are associated with acute inflammatory response, were exclusively regulated in the ileal mucosa of CD disease. In contrast, some genes encoding for lymphocyte receptors such as MS4A1, CD3D and CD79A were exclusively regulated in CD-MAT, exhibiting a different pattern of immune cell activation compared to the ileal mucosa in CD patients. qPCR and immunohistology confirmed the presence of large infiltrates of CD3+ CD20+ lymphocytes and CD138+ plasma cells in CD-MAT. Conclusion Our data strongly supports the role of CD-associated MAT as a site for T-, B- and plasma cell activation, and suggests that it could also act as a reservoir of memory immune responses.
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Fleming C, Mohan H, Coffey JC. Should we Resect the Mesentery in Ileocolic Crohn's Disease?-A Response to 'A Warning About the Role of Extended Mesenteric Resection in Crohn's Disease Recurrence'. J Crohns Colitis 2019; 13:1584. [PMID: 31211834 DOI: 10.1093/ecco-jcc/jjz121] [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: 12/30/2022]
Affiliation(s)
- Christina Fleming
- Department of Surgery, University Hospital Limerick Group, Limerick, Ireland
| | - Helen Mohan
- Department of Surgery, University Hospital Limerick Group, Limerick, Ireland
| | - John Calvin Coffey
- Department of Surgery, University Hospital Limerick Group, Limerick, Ireland.,Graduate Entry Medical School, 4i Centre for Interventions in Infection, Inflammation and Immunity, University of Limerick, Limerick, Ireland
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Ezzedine W, Frontali A, Panis Y. Controversies and future of minimally invasive surgery for inflammatory bowel disease. Cir Esp 2019; 98:503-506. [PMID: 31679740 DOI: 10.1016/j.ciresp.2019.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 07/21/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Walid Ezzedine
- Departamento de Cirugía Colorrectal, Pôle des Maladies de l'Appareil Digestif (PMAD), Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris (APHP), Université Paris VII (Denis Diderot), Clichy, Francia
| | - Alice Frontali
- Departamento de Cirugía Colorrectal, Pôle des Maladies de l'Appareil Digestif (PMAD), Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris (APHP), Université Paris VII (Denis Diderot), Clichy, Francia
| | - Yves Panis
- Departamento de Cirugía Colorrectal, Pôle des Maladies de l'Appareil Digestif (PMAD), Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris (APHP), Université Paris VII (Denis Diderot), Clichy, Francia.
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37
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D'Hoore A. Persistent Mesorectal Inflammatory Activity is Associated With Complications After Proctectomy in Crohn's Disease: Immediate Surgical Implications! J Crohns Colitis 2019; 13:271-272. [PMID: 30496367 DOI: 10.1093/ecco-jcc/jjy199] [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)
- André D'Hoore
- Department of Abdominal Surgery, University Hospital Gasthuisberg Leuven, Leuven, Belgium
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38
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Wickramasinghe D, Warusavitarne J. The role of the mesentery in reducing recurrence after surgery in Crohn's disease. Updates Surg 2019; 71:11-12. [PMID: 30712254 DOI: 10.1007/s13304-019-00623-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 01/04/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Dakshitha Wickramasinghe
- Department of Surgery, St. Mark's Hospital, London, UK. .,Department of Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
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Peltrini R, Bucci L. "Mesentery-based surgery" to prevent surgical recurrence in Crohn's disease: from basics to surgical practice. Int J Colorectal Dis 2019; 34:353-354. [PMID: 30417271 DOI: 10.1007/s00384-018-3197-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2018] [Indexed: 02/04/2023]
Affiliation(s)
- Roberto Peltrini
- Department of General and Specialist Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy.
| | - L Bucci
- Department of General and Specialist Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
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