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Carroll D, Kavalukas S. Management of Complications in Crohn's Disease. Adv Surg 2024; 58:19-34. [PMID: 39089776 DOI: 10.1016/j.yasu.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Complications of Crohn's disease reach far beyond postsurgical leak, infection, and enterocutaneous fistula. Malnutrition, intestinal failure, and recurrent disease all will require ongoing attentions. The management of these patients may further be complicated by the need for chronic immunosuppression. The underlying principles continue to include optimization of nutritional status, and preservation of bowel length when possible. However, there have been several recent advances in both the medical and surgical management of the disease. Understanding the contribution of the mesentery to inflammation, new surgical techniques such as the Kono-S anastomosis and extended mesenteric resection is decreasing the need for repeated resections.
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Affiliation(s)
- Dylan Carroll
- Department of Surgery, University of Louisville, 550 South Jackson Street, Louisville, KY 40292, USA
| | - Sandy Kavalukas
- Colorectal Surgery, Department of Surgery, University of Louisville, 550 South Jackson Street, Louisville, KY 40292, USA.
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Cathomas M, Saad B, Taha-Mehlitz S, Vankayalapati DK, Ghazal NE, Mourad MM, Ortlieb N, Than CA, Burri E, Glaser C, Heigl A, Neumann K, Honaker MD, Taha A, Rosenberg R. Safety and effectivity of Kono-S anastomosis in Crohn's patients: a systematic review and Meta-analysis. Langenbecks Arch Surg 2024; 409:227. [PMID: 39037448 PMCID: PMC11263246 DOI: 10.1007/s00423-024-03412-x] [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: 05/20/2024] [Accepted: 07/08/2024] [Indexed: 07/23/2024]
Abstract
PURPOSE Kono-S anastomosis, an antimesenteric, functional, end-to-end handsewn anastomosis, was introduced in 2011. The aim of this meta-analysis is to evaluate the safety and effectivity of the Kono-S technique. METHODS A comprehensive search of MEDLINE (PubMed), Embase (Elsevier), Scopus (Elsevier), and Cochrane Central (Ovid) from inception to August 24th, 2023, was conducted. Studies reporting outcomes of adults with Crohn's disease undergoing ileocolic resection with subsequent Kono-S anastomosis were included. PRISMA and Cochrane guidelines were used to screen, extract and synthesize data. Primary outcomes assessed were endoscopic, surgical and clinical recurrence rates, as well as complication rates. Data were pooled using random-effects models, and heterogeneity was assessed with I² statistics. ROBINS-I and ROB2 tools were used for quality assessment. RESULTS 12 studies involving 820 patients met the eligibility criteria. A pooled mean follow-up time of 22.8 months (95% CI: 15.8, 29.9; I2 = 99.8%) was completed in 98.3% of patients. Pooled endoscopic recurrence was reported in 24.1% of patients (95% CI: 9.4, 49.3; I2 = 93.43%), pooled surgical recurrence in 3.9% of patients (95% CI: 2.2, 6.9; I2 = 25.97%), and pooled clinical recurrence in 26.8% of patients (95% CI: 14, 45.1; I2 = 84.87%). The pooled complication rate was 33.7%. The most common complications were infection (11.5%) and ileus (10.9%). Pooled anastomosis leakage rate was 2.9%. CONCLUSIONS Despite limited and heterogenous data, patients undergoing Kono-S anastomosis had low rates of surgical recurrence and anastomotic leakage with moderate rates of endoscopic recurrence, clinical recurrence and complications rate.
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Affiliation(s)
- Marionna Cathomas
- Department of Surgery, Cantonal Hospital Baselland, Rheinstrasse 26, Liestal, 4410, Switzerland
| | - Baraa Saad
- School of Medicine, St George's University of London, London, SW17 0RE, UK
| | - Stephanie Taha-Mehlitz
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Dilip K Vankayalapati
- Stoke Mandeville Hospital, Buckinghamshire NHS Trust, Oxford Thames Valley, Aylesbury, UK
| | - Nour El Ghazal
- School of Medicine, St George's University of London, London, SW17 0RE, UK
| | | | - Niklas Ortlieb
- Medoc Swiss GMBH, Healthcare management, Basel, Switzerland
| | - Christian A Than
- School of Biomedical Sciences, The University of Queensland, St Lucia, Brisbane, 4072, Australia
| | - Emanuel Burri
- Department of Gastroenterology and Hepatology, Medical University Clinic, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Christine Glaser
- Department of Surgery, Cantonal Hospital Baselland, Rheinstrasse 26, Liestal, 4410, Switzerland
| | - Andres Heigl
- Department of Surgery, Cantonal Hospital Baselland, Rheinstrasse 26, Liestal, 4410, Switzerland
| | - Katerina Neumann
- Division of General Surgery, Dalhousie University, Nova scotia, Halifax, Canada
| | - Michael D Honaker
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Anas Taha
- Department of Surgery, Cantonal Hospital Baselland, Rheinstrasse 26, Liestal, 4410, Switzerland.
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA.
- Faculty of medicine, University of Basel, Basel, Switzerland.
| | - Robert Rosenberg
- Department of Surgery, Cantonal Hospital Baselland, Rheinstrasse 26, Liestal, 4410, Switzerland
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Menezes Nascimento Filho H, Kum AST, Bestetti AM, da Silva PHVA, Gallegos MMM, Damião AOMC, Navaneethan U, de Moura EGH. Patient-Related Factors Associated With Long-Term Outcomes After Successful Endoscopic Balloon Dilation For Crohn's Disease-Associated Ileo-Colic Strictures: A Systematic Review and Meta-analysis. CROHN'S & COLITIS 360 2024; 6:otae041. [PMID: 39175792 PMCID: PMC11339545 DOI: 10.1093/crocol/otae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Indexed: 08/24/2024] Open
Abstract
Background Successful Crohn's disease (CD) therapy relies on timely and precise management strategies. Endoscopic balloon dilation (EBD) has been applied as a first-line treatment for symptomatic CD-associated strictures due to its minimally invasive nature and the possibility of preserving intestinal length. Objective The aim of the present study was to determine patient-related predictive factors associated with the need for surgery for CD-associated ileocolic strictures after technically successful EBD. Methods All original studies published before December 2023 that reported the outcomes of patients treated with EBD for ileocolic strictures secondary to CD and described follow-up for at least 1 year were included. The difference in risk of needing surgery was calculated for 8 different patient characteristics (Sex, smoking habit, previous surgery, biologic therapy, steroids, immunosuppressors, nature of the stricture, and endoscopic disease activity). Results There were significant differences in the risk of needing surgery after EBD among patients who underwent surgery and patients without a history of surgery (RD: -0.20 [-0.31, -0.08]), patients with endoscopic mucosal activity and patients in remission at the time of EBD (RD: 0.19 [0.04, 0.34]), patients using biologics at the time of EBD and patients not using biologics (RD: -0.09 [-0.16, -0.03]), and patients using steroids and those not using steroids at the time of EBD (RD: 0.16 [0.07, 0.26]). Conclusions The use of biologics and endoscopic disease remission at the time of EBD were protective factors against the need for surgery. No previous surgery or use of steroids at the time of EBD was associated with the need for surgery during follow-up.
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Affiliation(s)
- Hiram Menezes Nascimento Filho
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Angelo So Taa Kum
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Alexandre Moraes Bestetti
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Megui Marilia Mansilla Gallegos
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Adérson Omar Mourão Cintra Damião
- Department of Gastroenterology and Hepatology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Udayakumar Navaneethan
- Orlando Health Digestive Health Institute Center for Advanced Endoscopy, Research and Education, Orlando, USA
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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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Dotlacil V, Lerchova T, Lengalova M, Kucerova B, Schwarz J, Hradsky O, Rygl M, Skaba R. Kono-S anastomosis in Crohn's disease: initial experience in pediatric patients. Pediatr Surg Int 2024; 40:67. [PMID: 38438752 DOI: 10.1007/s00383-024-05648-6] [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: 01/30/2024] [Indexed: 03/06/2024]
Abstract
PURPOSE Children diagnosed with Crohn's disease (CD) often undergo ileocecal resection (ICR) during childhood. Anastomotic recurrence is a frequent finding following this procedure. Data addressing the effect of the anastomosis type on disease recurrence are scarce in the pediatric population. The Kono-S anastomosis has shown promise in reducing endoscopic, clinical, and surgical recurrence rates in adults. We aimed to report our experience with Kono-S anastomosis in children, focusing on its feasibility and postoperative complications. METHODS We retrospectively analyzed pediatric CD patients who underwent ICR with Kono-S anastomosis between August 2022 and May 2023. Data on demographics, clinical characteristics, surgery, hospitalization, and follow-up including colonoscopy were collected. Complications were classified using the Clavien-Dindo classification. RESULTS Twelve patients (7 females, 58.3%) were included. Six (50%) of the patients had the B3 luminal form of the disease (according to Paris classification). Median surgery duration was 174 (interquartile range [IQR] 161-216) minutes. Anastomosis creation took a median of 62 (IQR, 54.5-71) minutes. Median hospitalization length was 6 (IQR 4-7) days. No short- or mid-term complications were observed. Median follow-up duration was 9.5 (IQR 6.8-12) months. CONCLUSION According to our results, Kono-S anastomosis is safe and feasible in pediatric CD patients, with no observed postoperative complications. These findings support the potential benefit of using Kono-S anastomosis as a treatment approach in children with CD.
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Affiliation(s)
- Vojtech Dotlacil
- Department of Paediatric Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Charles University, V Uvalu 84, 150 06, Praha 5, Czech Republic.
| | - Tereza Lerchova
- Department of Paediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | | | - Barbora Kucerova
- Department of Paediatric Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Charles University, V Uvalu 84, 150 06, Praha 5, Czech Republic
| | - Jan Schwarz
- Department of Paediatrics, Faculty of Medicine in Pilsen, Faculty Hospital, Charles University in Prague, Pilsen, Czech Republic
| | - Ondrej Hradsky
- Department of Paediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Michal Rygl
- Department of Paediatric Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Charles University, V Uvalu 84, 150 06, Praha 5, Czech Republic
| | - Richard Skaba
- Department of Paediatric Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Charles University, V Uvalu 84, 150 06, Praha 5, Czech Republic
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Doğru V, Ashburn JH, Akova U, Sutter AG, Esen E, Gardner EM, da Luz Moreira A, Erkan A, Kirat J, Grieco MJ, Remzi FH. Stapled End-To-Side Ileocolic Anastomosis in Crohn's Disease: Old Dog, Reliable Tricks? A Retrospective Two-Center Cohort Study. ANNALS OF SURGERY OPEN 2024; 5:e374. [PMID: 38883936 PMCID: PMC11175959 DOI: 10.1097/as9.0000000000000374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 12/08/2023] [Indexed: 06/18/2024] Open
Abstract
Objective Analyze our long-term experience with a less-popularized but stalwart approach, the stapled end-to-side ileocolic anastomosis. Background The choice of technical approach to ileocolic anastomosis after ileocecal resection for Crohn's disease affects surgical outcomes and recurrence. Yet, despite heterogeneous data from different anastomotic configurations, there remains no clear guidance as to the optimal technique. Methods In a retrospective cohort design, patients undergoing ileocolic anastomosis in the setting of Crohn's disease between 2016 and 2021 at two institutions were identified. Patient characteristics and surgical outcomes in terms of recurrence (surgical, clinical, and endoscopic) were studied. Results In total, 211 patients were included. Before surgery, 80% were exposed to at least 1 cycle of systemic steroids and 71% had at least 1 biologic agent; 60% exhibited penetrating disease and 38% developed an intra-abdominal abscess. After surgery, one anastomosis leaked (0.5%). Over 2.4 years of follow-up (IQR = 1.3-3.9), surgical recurrence was 0.9%. Two-year overall recurrence-free and endoscopic recurrence-free survivals were 74% and 85% (95% CI = 68-81 and 80-91), respectively. The adjusted hazard ratio of endoscopic recurrence was 3.0 (95% CI = 1.4-6.2) for males and 5.2 (1.2-22) for patients who received systemic steroids before the surgery. Conclusion The stapled end-to-side anastomosis is an efficient, reliable, and reproducible approach to maintain bowel continuity after ileocecal resection with durable outcomes. Our outcomes demonstrate low rates of disease recurrence and stand favorably in comparison to other more technically complex or protracted anastomotic approaches. This anastomosis is an ideal reconstructive approach after ileocecal resection for Crohn's disease.
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Affiliation(s)
- Volkan Doğru
- From the Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY
| | - Jean H Ashburn
- Department of Surgery, Wake Forest University Baptist Health, Winston-Salem, NC
| | - Umut Akova
- From the Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY
| | - Alton G Sutter
- Department of Surgery, Wake Forest University Baptist Health, Winston-Salem, NC
| | - Eren Esen
- From the Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY
| | - Emily M Gardner
- Department of Surgery, Wake Forest University Baptist Health, Winston-Salem, NC
| | | | - Arman Erkan
- From the Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY
| | - John Kirat
- From the Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY
| | - Michael J Grieco
- From the Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY
| | - Feza H Remzi
- From the Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY
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Bak MT, ten Bokkel Huinink S, Erler NS, Bodelier AG, Dijkstra G, Romberg-Camps M, de Boer NK, Hoentjen F, Stassen LP, van der Meulen–de Jong AE, West RL, van Ruler O, van der Woude CJ, de Vries AC. Prognostic Value of the Modified Rutgeerts Score for Long-Term Outcomes After Primary Ileocecal Resection in Crohn's Disease. Am J Gastroenterol 2024; 119:306-312. [PMID: 37737675 PMCID: PMC10833187 DOI: 10.14309/ajg.0000000000002509] [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: 06/08/2023] [Accepted: 08/29/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION The prognostic value of the modified Rutgeerts score (mRS) in patients with Crohn's disease (CD) needs to be further elucidated. This study assessed the prognostic value of the mRS for long-term outcomes after primary ileocecal resection in patients with CD. METHODS Patients with CD after primary ileocecal resection with an available mRS at first postoperative ileocolonoscopy (index mRS) were retrospectively included. The primary outcome was surgical recurrence. Secondary outcomes were clinical recurrence and progression to severe endoscopic recurrence (≥i3). Cox proportional hazard models were used to assess the association between index mRS and outcomes. RESULTS Six hundred fifty-two patients were included (mean follow-up: 6.4 years, SD: 4.6). Surgical recurrence rates were 7.7%, 5.3%, 12.9%, 19.1%, 28.8%, 47.8% for index mRS i0, i1, i2a, i2b, i3, and i4, respectively. Clinical recurrence occurred in 42.2% (i0), 53.7% (i1), 58.5% (i2a), 80.2% (i2b), 79.4% (i3), and 95.3% (i4) of patients. Progression to severe endoscopic recurrence occurred in 21.1% (i0), 33.9% (i1), 26.8% (i2a), and 33.3% (i2b) of patients. An index mRS of i2b (adjusted hazard ratio [aHR] 3.0; 1.5-5.6), i3 (aHR 4.0; 2.0-7.9) and i4 (aHR 8.0; 4.0-16.0) were associated with surgical recurrence. An index mRS of i1 (aHR 1.7; 1.2-2.4), i2a (aHR 1.7; 1.2-2.4), i2b (aHR 4.4; 3.2-6.0), i3 (aHR 3.6; 2.5-5.2), and i4 (aHR 7.3; 4.8-10.9) were associated with clinical recurrence. An index mRS of i1 (aHR 2.0; 1.1-3.7) or i2b (aHR 2.5; 1.4-4.6) was associated with progression to severe endoscopic recurrence. DISCUSSION The increasing mRS corresponds closely with the risk of surgical and clinical recurrence. An index mRS ≥ i2b is associated with surgical recurrence, an index mRS ≥ i1 is associated with clinical recurrence, and i1 or i2b with progression to severe endoscopic recurrence. These results support tight monitoring of disease activity and treatment optimization in patients with ileal lesions and a more conservative management in patients with anastomotic lesions.
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Affiliation(s)
- Michiel T.J. Bak
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sebastiaan ten Bokkel Huinink
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Nicole S. Erler
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Mariëlle Romberg-Camps
- Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Zuyderland Medical Centre, Heerlen-Sittard-Geleen, the Netherlands
| | - Nanne K.H. de Boer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
- Division of Gastroenterology, University of Alberta, Edmonton, Canada;
| | - Laurents P.S. Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Rachel L. West
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Oddeke van Ruler
- Department of Surgery, IJsselland Ziekenhuis, Cappelle aan den IJssel, the Netherlands
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - C. Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Annemarie C. de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
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Bachour SP, Click BH. Clinical Update on the Prevention and Management of Postoperative Crohn's Disease Recurrence. Curr Gastroenterol Rep 2024; 26:41-52. [PMID: 38227128 DOI: 10.1007/s11894-023-00911-7] [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] [Accepted: 12/27/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE OF REVIEW Despite advances in therapeutics, a significant portion of patients with Crohn's disease still require surgical management. In this article, we present updates to the natural history, prognostication and postoperative monitoring, and novel therapeutics in the prevention and treatment of postoperative Crohn's disease recurrence. RECENT FINDINGS Clinical risk factors have been associated with higher rates of postoperative recurrence (POR), and in recent studies demonstrate an increased cumulative risk with presence of additional risk factors. Additional novel clinical, histologic, and "-omic" risk factors for recurrence have recently been elucidated, including the role of the mesentery on recurrence and perioperative intraabdominal septic complications. High-risk patients benefit most from medical prophylaxis, including anti-TNF with or without immunomodulator therapy to prevent recurrence. New biologics such as vedolizumab and ustekinumab have emerging evidence in the use of prophylaxis, especially with recent REPREVIO trial data. Non-invasive disease monitoring, such as cross-sectional enterography, intestinal ultrasound, and fecal calprotectin, have been validated against ileocolonoscopy. Recent advances in the prediction, prevention, and monitoring algorithms of postoperative Crohn's disease may be leading to a reduction in postoperative recurrence. Ongoing trials will help determine optimal monitoring and management strategies for this at-risk population.
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Affiliation(s)
- Salam P Bachour
- Brigham and Women's Hospital, Department of Medicine, Boston, MA, 02115, USA
| | - Benjamin H Click
- University of Colorado Anschutz Medical Campus, Division of Gastroenterology and Hepatology, 13001 E 17th Pl, Aurora, CO, 80045, USA.
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Meijer LL, Ayez N, van Kessel CS. Crohn's disease: preserve or resect the mesentery? Br J Surg 2023; 110:1415-1418. [PMID: 37178332 DOI: 10.1093/bjs/znad135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/11/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023]
Affiliation(s)
| | - Ninos Ayez
- Department of Surgery, Amphia, Breda, The Netherlands
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Ning SB, Yang H, Li B, Zhang Y, Huang S, Peng B, Lin H, Kurban M, Li M, Guo Q. Balloon-assisted enteroscopy-based endoscopic stricturotomy for deep small bowel strictures from Crohn's disease: First cohort study of a novel approach. Dig Liver Dis 2023; 55:1397-1402. [PMID: 37316359 DOI: 10.1016/j.dld.2023.05.033] [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: 11/17/2022] [Revised: 04/25/2023] [Accepted: 05/29/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND There is little data on the role of endoscopic stricturotomy (ES) in treating deep small bowel strictures. We aimed to investigate the efficacy and safety of balloon-assisted enteroscopy-based ES (BAE-based ES) for deep small bowel strictures associated with Crohn's disease (CD). METHODS This multicentre retrospective cohort study included consecutive patients with CD-associated deep small bowel strictures treated with BAE-based ES between 2017 and 2023. The outcomes included technical success, clinical improvement, surgery-free rate, reintervention-free rate, and adverse events. RESULTS Twenty-eight patients with CD underwent 58 BAE-based ES procedures for non-passable deep small bowel strictures, with a median follow-up time of 519.5 days (interquartile range, 306-728 days). Fifty-six (96.0%) procedures were technically successful in 26 (92.9%) patients. Twenty patients (71.4%) showed clinical improvement at week 8. The cumulative surgery-free rate at 1 year was 74.8% (95% confidence interval [CI], 60.3-92.9%). A higher body mass index was associated with a decreased need for surgery (hazard ratio = 0.084, 95% CI, 0.016-0.45, P = 0.0036). Postprocedural adverse events (bleeding and perforation) requiring reintervention occurred in 3.4% of the procedures. CONCLUSIONS The novel BAE-based ES provides high technical success, favorable efficacy, and safety in CD-associated deep small bowel strictures, which may provide an alternative for endoscopic balloon dilation and surgery.
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Affiliation(s)
- Shou-Bin Ning
- Department of Gastroenterology, Digestive Endoscopy Center, Air Force General Hospital, the Fourth Military Medical University, Beijing, PR China.
| | - Hongsheng Yang
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China.
| | - Bairong Li
- Department of Gastroenterology, Digestive Endoscopy Center, Air Force General Hospital, the Fourth Military Medical University, Beijing, PR China
| | - Yiyang Zhang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing University, Nanjing, PR China
| | - Shuling Huang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing University, Nanjing, PR China
| | - Bo Peng
- Department of Small Bowel Endoscopy, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China; Department of Gastroenterology, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing University, Nanjing, PR China
| | - Huixian Lin
- Department of Small Bowel Endoscopy, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China; Department of Gastroenterology, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing University, Nanjing, PR China
| | - Mrigul Kurban
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China; Department of Gastroenterology, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing University, Nanjing, PR China
| | - Miao Li
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
| | - Qin Guo
- Department of Small Bowel Endoscopy, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China; Department of Gastroenterology, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing University, Nanjing, PR China; Department of Gastroenterology, the Third Xiangya Hospital of Central South University, Changsha, PR China.
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Bernstein CN, Regueiro M. Postoperative Crohn's Disease. J Clin Gastroenterol 2023; 57:749-753. [PMID: 37224283 DOI: 10.1097/mcg.0000000000001865] [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: 05/26/2023]
Abstract
Although surgery rates in Crohn's disease are declining in the past twenty years, bowel resection remains an important and still commonly used therapeutic option in Crohn's disease. Preoperatively, patients clinical status must be optimized including preparation for perioperative recovery including with nutrition optimization and preparation for postoperative pharmacotherapy. Postoperatively a medical therapy is often required and in recent years it has often been a biological therapy. One randomized controlled study suggested that infliximab is more likely to prevent endoscopic recurrence than placebo. But other biologicals have been used as well. Ileocolonoscopy should be undertaken by 6 months after an ileal or ileocecal resection especially. Adjunctive imaging such as transabdominal ultrasound, capsule endoscopy or cross sectional imaging may be required. Biomarker measurement with fecal calprotectin especially, or C-reactive protein, serum ferritin, serum albumin and serum hemoglobin will also be helpful.
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Affiliation(s)
- Charles N Bernstein
- University of Manitoba IBD Clinical and Research Centre and Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Miguel Regueiro
- Cleveland Clinic, Digestive Disease and Surgery Institute and Department of Medicine in the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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12
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Kelm M, Reibetanz J, Kim M, Schoettker K, Brand M, Meining A, Germer CT, Flemming S. Kono-S Anastomosis in Crohn's Disease: A Retrospective Study on Postoperative Morbidity and Disease Recurrence in Comparison to the Conventional Side-To-Side Anastomosis. J Clin Med 2022; 11:jcm11236915. [PMID: 36498490 PMCID: PMC9739288 DOI: 10.3390/jcm11236915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/17/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The rates of postoperative recurrence following ileocecal resection due to Crohn's disease remain highly relevant. Despite this fact, while the Kono-S anastomosis technique initially demonstrated promising results, robust evidence is still lacking. This study aimed to analyze the short- and long-term outcomes of the Kono-S versus side-to-side anastomosis. METHODS A retrospective single-center study was performed including all patients who received an ileocecal resection between 1 January 2019 and 31 December 2021 at the Department of Surgery at the University Hospital of Wuerzburg. Patients who underwent conventional a side-to-side anastomosis were compared to those who received a Kono-S anastomosis. The short- and long-term outcomes were analyzed for all patients. RESULTS Here, 29 patients who underwent a conventional side-to-side anastomosis and 22 patients who underwent a Kono-S anastomosis were included. No differences were observed regarding short-term postoperative outcomes. The disease recurrence rate postoperatively was numerically lower following the Kono-S anastomosis (median Rutgeert score of 1.7 versus 2.5), with a relevantly increased rate of patients in remission (17.2% versus 31.8%); however, neither of these results reached statistical significance. CONCLUSION The Kono-S anastomosis method is safe and feasible and potentially decreases the severity of postoperative disease remission.
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Affiliation(s)
- Matthias Kelm
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Joachim Reibetanz
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Mia Kim
- Department of Colorectal Surgery, Munich Hospital, Hospital Neuperlach/Harlaching, 81737 Munich, Germany
| | - Kathrin Schoettker
- Division of Gastroenterology, Department of Internal Medicine II, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Markus Brand
- Division of Gastroenterology, Department of Internal Medicine II, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Alexander Meining
- Division of Gastroenterology, Department of Internal Medicine II, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Sven Flemming
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
- Correspondence:
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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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