Postoperative Crohn's disease

Current approaches to the surgical management of Crohn's disease in Australia and New Zealand

PURPOSE

Given the evolving literature regarding the optimal surgical approach to mitigate post-operative recurrence of Crohn's disease (CD), this survey study aimed to elucidate the practices and preferences of colorectal surgeons in Australia and New Zealand (ANZ) in their surgical management of CD.

METHODS

Colorectal surgical consultants and fellows (n = 337) registered with the Colorectal Surgical Society of Australia and New Zealand (CSSANZ) were invited by email in April 2022 to participate in a cross-sectional survey consisting of basic demographics and 12 questions relating to their usual surgical practice and preferred operative strategy.

RESULTS

A total of 135 responses were received (39.9%). Regarding anastomotic configuration, 47% (n = 68) preferred the side-to-side anastomosis (STSA), 19% (n = 28) the end-to-end anastomosis (ETEA), and 15% (n = 21) the Kono S anastomosis. Most respondents preferred to resect at the proximal junction of the abnormal mesentery (75%, n = 97), while radical resection of the mesentery was preferred in 10% (n = 13) and close intestinal resection through abnormal mesentery in 15% (n = 20). The preferred surgical approach was by far laparoscopic (93%, n = 125) with extraction from the midline peri-umbilical port (80%, n = 108).

CONCLUSION

Amongst participating colorectal surgeons, there was a clear consensus on the approach, where the dominant practice was laparoscopy with a midline peri-umbilical extraction. Similarly, most respondents preferred some degree of mesenteric resection. However, anastomotic configuration and technique were domains of resection in CD lacking unanimity despite clear guidelines, highlighting an area requiring further attention.

Perianal fistulizing lesions of Crohn's disease are associated with long-term behavior and its transition: a Chinese cohort study

BACKGROUND/AIMS

Crohn's disease (CD) has a progressive nature and commonly perianal involvement. The aim of this study is to assess the prevalence, surgical treatment, and outcome of perianal fistulizing CD with associated risk factors in a large Chinese cohort.

METHODS

Hospitalized patients diagnosed with CD in our center were consecutively enrolled between January 2000 and December 2018. Transition of disease behavior was classified according to the presence or absence of penetrating behavior (B3 in the Montreal classification) at diagnosis and at a median follow-up of 102 months.

RESULTS

A total of 504 patients were included, of whom 207 (41.1%) were classified as B3 and 348 (69.0%) as L2/3 at follow-up. Transition of behavior to B3 was observed in 86 patients (17.1%). The incidence of perianal fistulizing lesions was 10.9% at 10 years with a final prevalence of 27.0% (n = 136) at the end of follow-up. Multivariate Cox regression identified independent risks of perianal fistulizing lesions for persistent B3 (hazard ratio, 4.72; 95% confidence interval, 1.91-11.66) and behavior transition of progressed to B3 (hazard ratio, 9.90; 95% confidence interval, 4.60-21.33). Perianal surgical treatments were performed in 104 patients (20.6%). Thirty-six cases (7.1%) were refractory, and it is independently associated with behavior of persistent B3 (P= 0.011).

CONCLUSIONS

Perianal fistulizing lesions occurred frequently in Chinese CD patients. Its incidence and refractory outcome were closely associated with the penetrating CD behavior. An additional risk of perianal fistulizing lesions was indicated for CD patients with behavior of progressing to B3, suggesting further attention.

Redo Ileocolic Resection for Crohn's Disease, Does It Palliate the Patients as Good as the Primary Resection?

Objective: We questioned how redo ileocolic resection (R-ICR) in Crohn's disease (CD) alleviates patients in the long-term compared with primary resection. Methods: A single-center retrospective analysis of patients who underwent an elective ICR without diversion between the years 2010-2022. The cohort was divided into two groups, namely, R-ICR and primary ileocolic resection (P-ICR). Results: The study included 181 patients, of which 30 patients are in the R-ICR group (mean age 42.3 years) and 151 patients in the P-ICR group (mean age 32.6 years). The R-ICR patients underwent an open approach (76.7% versus 25.2% among the P-ICR, p < .001), had significantly longer operations (mean 200.9 minutes versus 157.2 minutes, respectively, P = .002), and had higher estimated blood loss (mean 350 mL versus 267.4 mL, P = .043). The groups were similar in overall postoperative morbidity, severe postoperative complications (10% versus 13.2%, P = .762), and median length of hospital stay (12.1 days versus 7.4 days, P = .214). After a median follow-up of 64.2 months, there were no significant differences between the groups in terms of endoscopic recurrence (43.3% versus 60.9% in the P-ICR group, P = .104) or in clinical recurrence (43.3% versus 55.6%, respectively, P = .216), but the R-ICR had a significant higher rate of surgical recurrences (23.3% versus 5.3%, respectively, P = .004). Conclusion: R-ICR for CD is a significantly more challenging operation than the primary resection, and patients undergoing a R-ICR are more susceptible to a future surgical intervention than those having P-ICR.

Redo ileocolic resection in Crohn's disease - does time passed since previous surgery matter?

AIM

Surgical resection for Crohn's disease (CD) remains noncurative, therefore recurrence is a significant problem. Although numerous factors affecting surgical outcomes in redo ileocolic resection have been previously described, no study has considered the relation between the interval of time from initial ileocolic resection to the redo procedure and its effect on surgical outcomes. The aim of this study was to explore this relationship.

METHOD

A retrospective review of all adult patients undergoing redo ileocolic resection for CD between 2011 to 2020 was conducted. Patients were divided into two groups based on time from initial ileocolic resection. Patients operated within 10 years of their initial surgery (≤10 years) were assigned to the early group, while patients operated >10 years after initial surgery were allocated to the late group. Primary outcome was the 30-day postoperative major complication rate.

RESULTS

Fifty-eight patients underwent redo ileocolic resection, 24 in the early group and 34 in the late group. Apart from older median age in the late group (56 vs. 46.5 years, p = 0.026), the groups were similar for patient factors, disease site and behaviour, use of immune-suppressing medication and procedural factors. Significant differences in 30-day postoperative morbidity included longer length of stay (6 vs. 5 days, p = 0.035), a higher major complication rate (23.5% vs. 4.1%, p = 0.04) and higher readmission rate (26.4% vs. 4.1%, p = 0.035) in the late group. The overall complication rate remained nonsignificant (37.5% vs. 61.8%, p = 0.1).

CONCLUSIONS

Redo ileocolic resection, when performed >10 years from the initial ileocolic resection, may be associated with increased morbidity, specifically higher rates of major postoperative complications, a longer length of stay and more readmissions.

Postoperative Ratio of C-Reactive Protein to Albumin as a Predictive Marker in Patients with Crohn's Disease Undergoing Bowel Resection

Background

The ratio of C-reactive protein (CRP) to albumin (CAR) has a significant correlation with postoperative complications and acts as a predictor in patients with pancreatic cancer and colorectal cancer. However, whether the CAR can be used to predict complications in Crohn's disease (CD) patients after surgery has not yet been reported.

Methods

A total of 534 CD patients undergoing surgery between 2016 and 2020 were enrolled. The risk factors of postoperative complications were assessed by univariate and multivariate analyses. The cutoff values and the accuracy of diagnosis for the CAR and postoperative CRP levels were examined with receiver operating characteristic (ROC) curves.

Results

The rate of postoperative complications was 32.2%. The postoperative CAR (OR 13.200; 95% CI 6.501-26.803; P < 0.001) was a significant independent risk factor for complications. Compared with the CRP level on postoperative day 3, the CAR more accurately indicated postoperative complications in CD patients (AUC: 0.699 vs. 0.771; Youden index: 0.361 vs. 0.599). ROC curves showed that the cutoff value for the CAR was 3.25. Patients with a CAR ≥ 3.25 had more complications (P < 0.001), a longer postoperative stay (15.5 ± 0.6 d vs. 9.0 ± 0.2 d, P < 0.001), and more surgical site infections (48.2% vs. 5.7%, P < 0.001) than those with a CAR < 3.25.

Conclusions

Compared to the CRP level, the CAR can more accurately predict postoperative complications and can act as a predictive marker in CD patients after surgery.

Genetic Deletion of Tissue Inhibitor of Metalloproteinase-1/TIMP-1 Alters Inflammation and Attenuates Fibrosis in Dextran Sodium Sulphate-induced Murine Models of Colitis

BACKGROUND AND AIMS

Increased levels of tissue inhibitor of metalloproteinase-1 [TIMP-1] have been detected in both inflammatory and fibrotic lesions in Crohn's disease. In a murine model of chronic inflammation, fibrosis was associated with an increase in TIMP-1 and inhibition of matrix metalloproteinase [MMP]-mediated degradation. We investigated the effect of TIMP-1 deficiency in acute and chronic murine models of colitis.

METHODS

Colitis was induced via oral administration of dextran sodium sulphate [DSS] to B6.129S4-Timp1^tm1Pds/J knock-out [KO] and C57BL/6J wild-type [WT] mice. Levels of inflammation and fibrosis were assessed and gelatin zymographies and gene expression microarrays were performed.

RESULTS

Compared with WT mice, TIMP-1 KO mice had higher inflammatory parameters after acute DSS administration and developed less fibrosis after chronic DSS administration. MMP-2 levels were increased in WT versus TIMP-1 KO mice with acute colitis, whereas a trend for higher proMMP-9 levels was observed in WT versus TIMP-1 KO mice with chronic colitis. In control conditions, several immune-related genes [e.g Ido1, Cldn8] were differentially expressed between young TIMP-1 KO and WT mice, but to a lesser extent between older TIMP-1 KO and WT mice. In response to DSS, the gene expression pattern was significantly different between young TIMP-1 KO and WT mice, whereas it was similar in older TIMP-1 KO and WT mice.

CONCLUSIONS

TIMP-1 deficiency leads to differential expression of immune-related genes and to attenuated development of fibrosis. Unravelling the role of TIMP-1 in intestinal remodelling is necessary to develop more effective and more targeted therapeutic strategies for intestinal fibrosis.

Penetrating or stricturing diseases are the major determinants of time to first and repeat resection surgery in Crohn's disease

BACKGROUND

About 80% of patients with Crohn's disease (CD) require bowel resection and up to 65% will undergo a second resection within 10 years. This study reports clinical risk factors for resection surgery (RS) and repeat RS.

METHODS

Retrospective cohort study, using data from patients included in the Swiss Inflammatory Bowel Disease Cohort. Cox regression analyses were performed to estimate rates of initial and repeated RS.

RESULTS

Out of 1,138 CD cohort patients, 417 (36.6%) had already undergone RS at the time of inclusion. Kaplan-Meier curves showed that the probability of being free of RS was 65% after 10 years, 42% after 20 years, and 23% after 40 years. Perianal involvement (PA) did not modify this probability to a significant extent. The main adjusted risk factors for RS were smoking at diagnosis (hazard ratio (HR) = 1.33; p = 0.006), stricturing with vs. without PA (HR = 4.91 vs. 4.11; p < 0.001) or penetrating disease with vs. without PA (HR = 3.53 vs. 4.58; p < 0.001). The risk factor for repeat RS was penetrating disease with vs. without PA (HR = 3.17 vs. 2.24; p < 0.05).

CONCLUSION

The risk of RS was confirmed to be very high for CD in our cohort. Smoking status at diagnosis, but mostly penetrating and stricturing diseases increase the risk of RS.

CT enterography in evaluating postoperative recurrence of Crohn's disease after ileocolic resection: complementary role to endoscopy

BACKGROUND

Ileocolonoscopy is the gold standard to assess postoperative recurrence (POR) in patients with Crohn's disease (CD) who have undergone ileocolic resection. Although computed tomographic enterography (CTE) yields striking findings in the small bowel of CD, its role in POR is undefined. The aim of this study was to compare ileocolonoscopy and CTE for evaluating POR in CD.

METHODS

The analysis included 32 patients with CD with ileocolic resection. Ileocolonoscopy and CTE were performed within 1 week. Endoscopic recurrence was defined using Rutgeerts score (i0-i4), whereas CTE recurrence was assessed according to a previously validated CTE score (CTE0-CTE3). Patients were followed up for a maximum of 30 months, and the primary endpoint was reoperation.

RESULTS

There was a good correlation between endoscopic and CTE recurrence (r = 0.782, P < 0.0001). Moreover, CTE identified the presence of jejunal and proximal ileum disease (n = 7), fistula (n = 3), and abscess (n = 4). Therapeutic management was thereby modified in 8 of 32 patients (25.0%). Eleven patients received major reoperation. There was no significant difference regarding the rate of reoperation between subgroups' Rutgeerts score i3-4 and i0-2 (P > 0.05), whereas there was significant difference between subgroups' CTE2-CTE3 and CTE0-CTE1 (P < 0.05).

CONCLUSIONS

CTE is a reliable method in assessing POR in patients with CD who have undergone ileocolic resection. CTE may serve as an important complementary tool to endoscopy for evaluation of the postoperative course of CD.

Clinical course of intestinal Behcet's disease during the first five years

BACKGROUND

Little is known about the clinical course of patients with intestinal Behcet's disease (BD). We aimed to evaluate the clinical course of intestinal BD during the first 5 years after diagnosis, and to identify factors that could predict the 5-year clinical course.

METHODS

We reviewed the medical records of 130 intestinal BD patients who were regularly followed-up for at least 5 years at a single tertiary academic medical center between March 1986 and September 2011.

RESULTS

Of the five different clinical course patterns that we observed, persistent remission or mild clinical activity was the most frequent course (56.2 %). The majority of patients (74.6 %) had remission or mild clinical activity at 5 years, and only the minority (16.2 %) had multiple relapses or chronic symptoms. The clinical course of the first year after diagnosis of intestinal BD influenced the clinical course of the following years. Patients in the severe clinical course group were younger, and had a higher ESR, CRP level, and disease activity index for intestinal Behcet's disease (DAIBD), and lower albumin level at diagnosis than patients in the mild clinical course group. Initial presentation with a high DAIBD was independently associated with a severe clinical course.

CONCLUSIONS

The clinical course of intestinal BD during the first 5 years was variable. A substantial proportion of patients went into remission or had a mild clinical activity, while some patients had a severe, debilitating clinical course as time progressed. High disease activity at diagnosis was a negative prognostic predictor.

Long-term clinical outcomes of Crohn's disease and intestinal Behcet's disease

BACKGROUND

Crohn's disease (CD) and intestinal Behcet's disease (BD) are transmural inflammatory diseases with fluctuating courses characterized by repeated episodes of relapse and remission that often require operation or reoperation. However, no study has directly compared the long-term prognoses of these two diseases.

METHODS

We reviewed the medical records of 332 patients with CD and 276 patients with intestinal BD who were regularly followed up at a single tertiary academic medical center in Korea between March 1986 and July 2010. The clinical outcomes after diagnosis and surgery were analyzed using the Kaplan-Meier method and log-rank test.

RESULTS

There were no significant differences in the cumulative probabilities of surgery (29.4% and 36.0% vs. 31.6% and 44.4% at 5 and 10 years, respectively: P = 0.287) or admission (66.1% and 73.8% vs. 59.0% and 69.2%, P = 0.259) between CD and intestinal BD. Furthermore, no differences were observed between the two diseases for the cumulative probabilities of postoperative clinical recurrence (P = 0.724) and reoperation (P = 0.770). However, the cumulative probabilities of corticosteroid use (63.8% and 76.6% vs. 42.6% and 59.4% at 5 and 10 years, respectively: P < 0.001) and immunosuppressant use (49.1% and 65.5% vs. 27.1% and 37.7%, P < 0.001) were significantly higher in CD patients than in intestinal BD patients.

CONCLUSIONS

There were no significant differences in the long-term clinical outcomes and postoperative prognoses between CD and intestinal BD, although CD patients required corticosteroid or immunosuppressant therapy more often than intestinal BD patients.

Positive histological inflammatory margins are associated with increased risk for intra-abdominal septic complications in patients undergoing ileocolic resection for Crohn's disease

BACKGROUND

Rates of postoperative complications are particularly high among patients with Crohn's disease.

OBJECTIVE

The aim of this study was to assess whether positive inflammatory histological margins, among other factors, pose a risk for intra-abdominal septic complications in patients with Crohn's disease undergoing ileocolic resection.

DESIGN

A retrospective study of patient records, during 2000-2010, was conducted.

SETTINGS

This investigation was performed at a single medical center.

PATIENTS

Included were 166 individuals with Crohn's disease (85 males, mean age 35.6).

INTERVENTION

Ileocolic resection with primary anastomosis was performed.

MAIN OUTCOME MEASURE

The primary outcomes measured were postoperative intra-abdominal septic complications.

RESULTS

Twenty-five patients (15%) developed intra-abdominal septic complications, including anastomotic leak, intra-abdominal abscesses and collections, and enterocutaneous fistulas. There were no postoperative deaths. Univariate analysis revealed that a long course of disease before surgery, an emergency surgery, steroid treatment of more than 3 months before surgery, additional sigmoidectomy, and positive surgical margins detected on histopathological examination were associated with intra-abdominal septic complications. In a multivariate analysis, only disease duration longer than 10 years (OR 4.575 (CI 1.592-13.142), p = 0.005), additional sigmoidectomy (OR 5.768 (CI 1.088-30.568), p = 0.04), and positive histological resection margins (OR 2.996 (CI 1.085-8.277), p = 0.03) were found to be independent risk factors.

LIMITATIONS

This study was limited by the incomplete data regarding preoperative albumin levels.

CONCLUSIONS

Positive histological margins, disease duration of more than 10 years, and added sigmoidectomy are independent risk factors that are associated with postoperative intra-abdominal septic complications in patients undergoing ileocolic resection for Crohn's disease. These risk factors should be considered when the need for a diverting stoma is questionable. A frozen section of the margins may assist in the decision as to a temporary ileostomy construction.

Animal models of intestinal fibrosis: new tools for the understanding of pathogenesis and therapy of human disease

Fibrosis is a serious condition complicating chronic inflammatory processes affecting the intestinal tract. Advances in this field that rely on human studies have been slow and seriously restricted by practical and logistic reasons. As a consequence, well-characterized animal models of intestinal fibrosis have emerged as logical and essential systems to better define and understand the pathophysiology of fibrosis. In point of fact, animal models allow the execution of mechanistic studies as well as the implementation of clinical trials with novel, pathophysiology-based therapeutic approaches. This review provides an overview of the currently available animal models of intestinal fibrosis, taking into consideration the methods of induction, key characteristics of each model, and underlying mechanisms. Currently available models will be classified into seven categories: spontaneous, gene-targeted, chemical-, immune-, bacteria-, and radiation-induced as well as postoperative fibrosis. Each model will be discussed in regard to its potential to create research opportunities to gain insights into the mechanisms of intestinal fibrosis and stricture formation and assist in the development of effective and specific antifibrotic therapies.

Is laparoscopic surgery for recurrent Crohn's disease beneficial in patients with previous primary resection through midline laparotomy? A case-matched study

BACKGROUND

Patients undergoing abdominal surgery for Crohn's disease are predisposed to recurrence requiring reoperation. The effectiveness of laparoscopic versus open resection in patients with previous intestinal resection for Crohn's through midline laparotomy is controversial.

METHODS

Patients with previous open resection for intestinal Crohn's disease undergoing elective laparoscopic surgery for recurrent bowel disease from 1997 to 2011 were case-matched with open counterparts based on age (±5 years), gender, body mass index (±2 kg/m(2)), American Society of Anesthesiologists (ASA) score, surgical procedure, and year of surgery (±3 years). Groups were compared using Chi-square or Fisher exact tests for categorical and the Wilcoxon rank-sum test for quantitative data.

RESULTS

26 patients undergoing laparoscopic ileocolectomy (n = 14), proctocolectomy (n = 5), small bowel resection (n = 4), abdominoperineal resection (n = 1), extended right colectomy (n = 1), and strictureplasty (n = 1) were well matched to 26 patients undergoing open surgery. The number of previous operations, disease phenotypes, steroid use, and comorbidities were comparable in the two groups. There were no deaths, and three patients (12%) required conversion because of adhesions. Laparoscopic and open groups had statistically similar operating times (169 versus 158 min, p = 0.94), estimated blood loss (222 versus 427 ml, p = 0.32), overall morbidity (39 versus 69%, p = 0.051), reoperation rates (8 versus 0%, p = 0.5), postoperative return of bowel function (3.5 ± 1.4 versus 3.9 ± 1.7 days, p = 0.3), mean length of hospital stay (6.4 ± 6.2 versus 6.9 ± 3.5 days, p = 0.12), and readmission rates (8 versus 12%, p = 0.64). Wound infection rate was decreased after laparoscopic surgery (0 versus 27%, p = 0.01).

CONCLUSIONS

Surgery for recurrent Crohn's disease in patients with previous primary resection through laparotomy can be frequently and safely completed laparoscopically. Wound infection rates are reduced, but the recovery advantages of a minimally invasive approach are not maintained when compared with open surgery. The decision to operate laparoscopically should therefore be carefully calibrated.

Split stoma in resectional surgery of high-risk patients with ileocolonic Crohn's disease

AIM

The aim of this retrospective study of ileocolonic resection in patients with Crohn's disease was to compare the outcome of primary anastomosis with that of split stoma and delayed anastomosis in a high-risk setting.

METHOD

From 1995 to 2006, 132 patients had 146 operations for ileocolonic Crohn's disease. Preoperative data, including risk factors for complications, were obtained from a prospectively registered database. Operations on patients who had two or more preoperative risk factors (n = 76) were considered to be high-risk operations and formed the main study. Primary outcome variables were postoperative anastomotic complications and the alteration in the number of preoperative risk factors achieved by a delayed anastomosis. Secondary outcome was time in hospital and the number of operations performed.

RESULTS

Early anastomotic complications were diagnosed in 19% (11/57) of patients receiving a primary anastomosis compared with 0% (0/19) of patients after a delayed anastomosis (P = 0.038). The mean number of risk factors in the split stoma group was 3.5 at the time of resection and 0.2 when the split stoma was reversed (P < 0.0001). The total number of operations was 1.9 ± 1.5 (mean ± SD) after a primary anastomosis and 2.0 ± 0.2 after a split stoma (P = 0.70). Total in-hospital time for all operations was 20.9 ± 35.6 days after a primary anastomosis and 17.8 ± 10.4 days after a delayed anastomosis (P = 0.74).

CONCLUSION

Delayed anastomosis after ileocolonic resection in high-risk Crohn's disease patients was associated with a reduction in the number of preoperative risk factors and fewer anastomotic complications. Hospital stay and number of operations were similar after delayed and primary anastomosis in high-risk patients.

Co-morbid diabetes in patients with Crohn's disease predicts a greater need for surgical intervention

BACKGROUND

The prevalence of diabetes is increasing rapidly. Given its pro-inflammatory nature, comorbid diabetes may affect the course of Crohn's disease (CD).

AIM

To determine whether comorbid diabetes influences the natural history of CD.

METHODS

We compared a cohort with CD and comorbid diabetes to a nondiabetic control population and calculated the period prevalence of surgical intervention over a 5-year period. Unadjusted and adjusted odds-ratios were calculated regarding the need for surgical intervention using univariate and multivariate logistic regression.

RESULTS

A total of 240 patients were identified, 16 of whom were diabetics (6.7%). The period prevalence of CD-specific surgery in the diabetic cases was 75.0% and in the nondiabetic controls, 31.7%. The diabetic patients were more obese than the controls (44% vs. 10%; P < 0.0001) and older than the controls (47.4 years vs. 38.6; P < 0.01). There was no difference in the frequency of biologic therapy use, immunomodulator use, smoking, perianal disease, ileal involvement or corticosteroid use between the diabetics and controls. Univariate analysis revealed that diabetes (OR 6.46 [95% CI 2.01-20.8]), smoking (OR 2.46 [95% CI 1.24-4.90]), ileal disease (OR 2.21 [95% CI 1.15-4.24]) and obesity (OR 2.22 [95% CI 1.04-4.77]) were risk factors for needing surgery. After adjustment for covariates, the OR for surgical intervention in diabetics was 5.4 (95% CI 1.65-17.64).

CONCLUSION

Co-morbid diabetes in patients with Crohn's disease predicts a greater need for surgical intervention.

Factors associated with operative recurrence early after resection for Crohn's disease

INTRODUCTION

Some Crohn's disease (CD) patients develop rapid disease recurrence requiring reoperation. Identification of factors associated with early operative recurrence of CD may help risk-stratify patients and prevent recurrence.

METHODS

Prospectively collected data of CD patients undergoing bowel resection for CD with unequivocal evidence of recurrence at reoperation were retrieved. Patients with earlier recurrence (less than median time of recurrence of study cohort) were compared with those who developed later recurrence (greater than median time of recurrence) for patient and disease characteristics and risk factors for recurrence. A multivariate logistic regression model was performed to identify factors associated with earlier operative recurrence.

RESULTS

Sixty-nine patients (45 female, 24 male) met the inclusion criteria. Median time to reoperation was 38 months (range, 3.3-236 months). One hundred six reoperations in the 69 patients were for abscess/fistula/perforation (n = 45), stricture/stenosis (n = 41), inflammation (n = 17), bleeding (n = 2), and dysplasia (n = 1). Factors associated with early rather than late reoperation included behavior of disease (stricturing, odds ratio (OR) 12.1; confidence interval (CI), 1.8-80.9; penetrating OR, 9.9; CI, 1.4-67.9 rather than nonstricturing nonpenetrating) and the development of postoperative complications at previous surgery (OR, 12.1; CI, 1.2-126.6).

CONCLUSION

Earlier recurrence of CD requiring reoperation is associated with specific disease and potentially modifiable operation-related factors such as postoperative complications, i.e., anastomotic leak or intraabdominal abscess. Strategies to reduce recurrence in such patients include the identification of factors that may reduce postoperative complications.

A claims-based Markov model for Crohn's disease

BACKGROUND

Crohn's disease is a chronic condition that often presents in early adulthood.

AIM

To evaluate health care costs and costs per quality-adjusted life year (QALY) for Crohn's disease.

METHODS

A Markov model was developed using administrative claims data for patients aged > or = 18 years with > or = 3 years of continuous enrolment from 2000 to 2008 and > or =2 Crohn's disease claims. Disease states (remission, mild-moderate, moderate-severe, and severe-fulminant) were defined using the American College of Gastroenterology treatment guidelines criteria. Transition probabilities were calculated from consecutive 6-month periods. Costs were determined from paid claims and QALY utilities were obtained from the literature. The model assumed a 30-year-old patient at the time of entry into the model.

RESULTS

There were 40 063 patients identified, with a total of 420 773 cycles [remission (197 111; 46.8%), mild-moderate (44 024; 10.5%), moderate-severe (132 695; 31.5%), severe-fulminant (46 925; 11.2%)]. The costs/QALY for remission, mild-moderate, moderate-severe, and severe-fulminant disease states respectively were $2896, $8428, $11 518 and $69 277 for males and $2896, $8426, $22 633 and $69 412 for females.

CONCLUSIONS

Overall, health care costs for patients with Crohn's disease increased with disease severity. Although the probabilities of transitioning from other health states to the severe-fulminant disease state were low, the cost/QALY was high.

Reoperative inflammatory bowel disease surgery

With the advent of restorative proctocolectomy or ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), not only has there been potential for cure of UC but also patients have enjoyed marked improvements in bowel function, continence, and quality of life. However, IPAA can be complicated by postoperative small bowel obstruction, disease recurrence, and pouch failure secondary to pelvic sepsis, pouch dysfunction, mucosal inflammation, and neoplastic transformation. These may necessitate emergent or expeditious elective reoperation to salvage the pouch and preserve adequate function. Local, transanal, and transabdominal approaches to IPAA salvage are described, and their indications, outcomes, and the clinical parameters that affect the need for salvage are discussed. Pouch excision for failed salvage reoperation is reviewed as well. Relaparotomy is also frequently required for recurrent Crohn's disease (CD), especially given the nature of this as yet incurable illness. Risk factors for CD recurrence are examined, and the various surgical options and margins of resection are evaluated with a focus on bowel-sparing policy. Stricturoplasty, its outcomes, and its importance in recurrent disease are discussed, and segmental resection is compared with more extensive procedures such as total colectomy with ileorectal anastomosis. Lastly, laparoscopy is addressed with respect to its long-term outcomes, effect on surgical recurrence, and its application in the management of recurrent CD.

Inflammation enhances resection-induced intestinal adaptive growth in IL-10 null mice

BACKGROUND

Surgical resection of the ileum, cecum, and proximal right colon (ICR) is common in the management of Crohn's disease, yet little is known about the effect of active inflammation on the adaptive response following intestinal loss. We recently developed a surgical model of ICR in germ-free (GF) IL-10 null mice that develop small intestinal inflammation only when mice undergo conventionalization with normal fecal microflora (CONV) before surgical intervention. In this study, we examined the effects of postsurgical small bowel inflammation on adaptive growth after ICR.

METHODS

GF 129SvEv IL-10 null mice, 8-10 wk old, were allocated to GF or CONV groups. Nonoperated GF and CONV mice provided baseline controls. Two wk later, GF and CONV mice were further allocated to ICR or sham operation. Small intestine and colon were harvested 7 d after surgery for histological analysis.

RESULTS

All mice within the gnotobiotic facility maintained GF status and did not develop small intestinal or colonic inflammation. CONV resulted in colitis in all groups, whereas small intestinal inflammation was only observed following ICR. Resection-induced small intestinal inflammation in CONV mice was associated with increases in proliferation, crypt depth, and villus height compared with GF mice after ICR. Resection-induced increases in crypt fission only occurred in CONV mice.

CONCLUSION

ICR-dependent small intestinal inflammation in CONV IL-10 null mice dramatically enhances early adaptive growth of the small intestine. Additional studies utilizing our model may provide clinical insight leading to optimal therapies in managing IBD patients after surgical resection.

Meta-analysis of medical treatment and placebo treatment for preventing postoperative recurrence in Crohn's disease (CD)

INTRODUCTION

We performed a meta-analysis to compare the clinical and endoscopic recurrence of medical treatment and placebo treatment for preventing postoperative recurrence in Crohn's disease.

MATERIALS AND METHODS

Trials were located through Medline, Embase, the Cochrane Central Register of Controlled Trials, Ovid, Sciencedirect, and Ingenta electronic databases. From 124 articles screened, 14 were identified as randomized placebo-controlled trials and were included for data extraction. Main outcome measures were clinical recurrence, endoscopic recurrence, and severe endoscopic recurrence. The meta-analysis was performed with the fixed-effects model.

RESULT

Fourteen studies with 1,497 participants were analyzed. In the intention-to-treat analysis, medical treatment was associated with a significantly lower incidence of clinical recurrence (relative risk of 0.74, 95% confidence interval 0.64-0.87, P = 0.000], but there were no significant differences in endoscopic recurrence (0.94, 0.83-1.07, P = 0.353) and severe endoscopic recurrence (0.83, 0.60-1.16, P = 0.281) between the two groups. When using per-protocol analysis, the results is similar, medical treatment was associated with a significantly lower incidence of clinical recurrence (0.84, 0.72-0.97, P = 0.020), but there were no significant differences in endoscopic recurrence (0.94, 0.85-1.05, P = 0.268) or severe endoscopic recurrence (0.76, 0.55-1.04, P = 0.084) between the two groups of patients.

CONCLUSIONS

Medical treatment has a sufficiently beneficial effect on decreasing the risk of clinical postoperative recurrence in patients with CD.

Clinical course of Crohn's disease first diagnosed at surgery for acute abdomen

BACKGROUND

The severity of clinical activity of Crohn's disease is high during the first year after diagnosis and decreases thereafter. Approximately 50% of patients require steroids and immunosuppressants and 75% need surgery during their lifetime. The clinical course of patients with Crohn's disease first diagnosed at surgery has never been investigated.

AIM

To assess the clinical course of Crohn's disease first diagnosed at surgery for acute abdomen and to evaluate the need for medical and surgical treatment in this subset of patients.

PATIENTS AND METHODS

Hospital clinical records of 490 consecutive Crohn's disease patients were reviewed. Patients were classified according to the Vienna criteria. Sex, extraintestinal manifestations, family history of inflammatory bowel diseases, appendectomy, smoking habit and medical/surgical treatments performed during the follow-up period were assessed.

STATISTICAL ANALYSIS

Kaplan-Meier survival method and Cox proportional hazards regression model.

RESULTS

Of the 490 Crohn's disease patients, 115 had diagnosis of Crohn's disease at surgery for acute abdomen (Group A) and 375 by conventional clinical, radiological, endoscopic and histologic criteria (Group B). Patients in Group A showed a low risk of further surgery (Log Rank test p<0.001) and a longer time interval between diagnosis and first operation compared to Group B (10.8 years vs. 5.8 years, p<0.01, respectively). Furthermore, patients in Group A used less steroids and immunosuppressants (OR 0.3, p<0.0001; OR 0.6, p<0.004, respectively).

CONCLUSIONS

Crohn's disease patients first diagnosed at surgery for acute abdomen showed a low risk for reintervention and less use of steroids and immunosuppressants during follow-up than those not operated upon at diagnosis. Early surgery may represent a valid approach in the initial management of patients with Crohn's disease, at least in the subset of patients with ileal and complicated disease.

Intraabdominal septic complications following bowel resection for Crohn's disease: detrimental influence on long-term outcome

BACKGROUND

A number of studies deal with factors affecting postoperative recurrence; however, they do not analyze the influence of postoperative morbidity on the long-term outcome. This was the aim of the present study.

MATERIALS AND METHODS

Two hundred eighty-two patients underwent 331 intestinal resections for primary or recurrent Crohn's disease between 1992 and 2005. Closure of ileostomy or colostomy, isolated stricturoplasty, abdominoperineal resection for perianal disease, and reoperations for postoperative complications were excluded. "Surgical recurrence" was defined as a development of stricturing or perforating disease necessitating repeat surgical therapy.

RESULTS

Anastomotic leak, intraabdominal abscess, enterocutaneous fistula (intraabdominal septic complications, IASC) occurred after 46 operations (16%). Four patients died (1.2%). By multivariate analysis, articular disease manifestation (p = 0.03), duration of symptoms leading to surgery (p = 0.009), and weight loss (p = 0.03) were associated with occurrence of postoperative complications. Surgical recurrence occurred following 86 bowel resections, and 36 occurred during the first postoperative year. The following factors were associated with an increased risk of surgical recurrence by multivariate analysis: postoperative IASC (p = 0.0002) and previous bowel resections (p = 0.002). Patients suffering IASC had statistically significantly higher 1-, 2-, 5-, and 10-year surgical recurrence rate (25%, 29%, 50%, and 57%) than patients without IASC (4%, 7%, 19%, and 38%, p = 0.0003).

CONCLUSION

The incidence of the postoperative IASC is predominantly determined by preoperative disease severity. IASC have a detrimental influence on the long-term outcome following intestinal resections in patients with Crohn's disease, leading to increased number of repeat resection surgery.

Postoperative Crohn’s disease recurrence: A practical approach

Crohn's disease is a chronic inflammatory condition that may involve any segment of the gastrointestinal tract. Although several drugs have proven efficacy in inducing and maintaining disease in remission, resectional surgery remains as a cornerstone in the management of the disease, mainly for the treatment of its stenosing and penetrating complications. However, the occurrence of new mucosal (endoscopic) lesions in the neoterminal ileum early after surgery is almost constant, it is followed in the mid-term by clinical symptoms and, in a proportion of patients, repeated intestinal resections are required. Pathogenesis of postoperative recurrence (POR) is not fully understood, but luminal factors (commensal microbes, dietary antigens) seem to play an important role, and environmental and genetic factors may also have a relevant influence. Many studies tried to identify clinical predictors for POR with heterogeneous results, and only smoking has repeatedly been associated with a higher risk of POR. Ileocolonoscopy remains as the gold standard for the assessment of appearance and severity of POR, although the real usefulness of the available endoscopic score needs to be revisited and alternative techniques are emerging. Several drugs have been evaluated to prevent POR with limited success. Smoking cessation seems to be one of the more beneficial therapeutic measures. Aminosalicylates have only proved to be of marginal benefit, and they are only used in low-risk patients. Nitroimidazolic antibiotics, although efficient, are associated with a high rate of intolerance and might induce irreversible side effects when used for a long-term. Thiopurines are not widely used after ileocecal resection, maybe because some concerns in giving immunomodulators in asymptomatic patients still remain. In the era of biological agents and genetic testing, a well-established preventive strategy for POR is still lacking, and larger studies to identify good clinical, serological, and genetic predictors of early POR as well as more effective drugs (or drug combinations) are needed.

Operative management of Crohn's disease of the colon including anorectal disease

Evaluation and management of the patient who has Crohn's disease of the colon, rectum, and anus is challenging for even the most experienced provider. Because of its broad spectrum of presentation, recurrent nature, and potential for high morbidity, the surgeon needs to not only treat the acute situation but also keep in mind the potential long-term ramifications. Although there are exciting new medications and treatment modalities yielding promising results, surgery continues to remain at the forefront for the care of these patients. This article reviews various surgical options for the patient who has Crohn's disease of the colon, rectum, and perianal region with emphasis on symptomatic resolution and optimization of function.

Efficacy and safety of oral beclomethasone dipropionate for ileal or ileal-right colon Crohn's disease of mild-to-moderate activity or in remission: Retrospective study

Although conventional glucocorticosteroids are the main treatments for active Crohn's disease, several problems are associated with steroid dependence and steroid-related adverse events. To assess the efficacy and safety of oral beclomethasone dipropionate (BDP) coated tablets in adults with mild-to-moderate Crohn's disease. Thirty-four patients (age 18-70years) with a diagnosis of Crohn's disease confirmed by conventional criteria (barium enema, clinical criteria, colonoscopy, histology) were retrospectively evaluated in the study. All subjects received a treatment schedule with BDP 5-10mg/day for 24weeks. BDP significantly (p=0.005) reduced mean Crohn's Disease Activity Index (CDAI) score from 169.6 at baseline to 123.2 after 24weeks. Clinical success was evident at 24weeks in 66.7% of patients with initial active disease, and remission was maintained at week 24 in 93.8% of patients with remission at baseline. Overall, female non-smokers had the best response to treatment. BDP was well tolerated and the only adverse events observed were nausea (n=1), facial erythema (n=1) and one patient with raised fasting blood glucose level. These results clearly suggest that oral BDP coated tablets are effective and safe for treatment of mild-to-moderate Crohn's disease of ileal or ileal-right colonic localisation.

Multicenter randomized-controlled clinical trial of probiotics (Lactobacillus johnsonii, LA1) on early endoscopic recurrence of Crohn's disease after lleo-caecal resection

BACKGROUND

Seventy percent of Crohn's disease (CD) patients exhibit anastomotic recurrence within 1 year after ileo-caecal surgery. Recent clinical trials suggest the beneficial use of probiotics in the control of intestinal inflammation in pouchitis and ulcerative colitis. This study is a multicenter clinical trial evaluating the efficacy of an oral administration of the probiotic LAl on early post-operative endoscopic recurrence of CD.

METHODS

Seventy patients with CD were enrolled prior to elective ileo-caecal resection and randomly assigned after surgery to daily treatment with either Lactobacillus johnsonii, LA1, Nestle (1010 colony-forming units, CFU) (group A, n = 34) or placebo (group B, n = 36) for 12 weeks. The primary objective was to assess the effect of LAl on the endoscopic recurrence rate at 12 weeks. Stratification was performed according to smoking status at randomization.

RESULTS

Seven and 14 patients were excluded in the LA1 and placebo groups, respectively. In intention-to-treat analysis, the mean endoscopic score was not significantly different between the two treatment groups at 3 months (LA1 versus placebo: 1.50 +/- 1.32 versus 1.22+/-1.37, treatment effect: P = 0.48, smoke effect: P = 0.72). The percentage of patients with severe recurrence (i3 + i4) was 21% and 15% in the LAl and placebo groups, respectively (P = 0.33). Using a per-protocol (PP) analysis, the mean endoscopic score was not significantly different between the two treatment groups (LAl versus placebo groups: 1.44 +/-1.31 versus 1.05 +/- 1.21, P = 0.32). The percentage of patients with severe recurrence (i3 + i4) was 19% and 9% in the LAl and placebo groups, respectively (P = 0.054). Clinical relapse rate (CDAI [CD activity index] > 150, with an increase of CDAI > 70 points or greater from baseline) in the LAl and placebo groups was 15% (4/27) and 13.5% (3/22), respectively (PP analysis: chi-square test, P = 0.91 and log-rank test: P = 0.79).

CONCLUSION

Oral administration of the probiotic LA1 in patients with CD failed to prevent early endoscopic recurrence at 12 weeks after ileo-caecal resection.

Surgical approaches to cancer in patients who have inflammatory bowel disease

IBD clearly increases the risk for GI malignancies, especially CRC. The absolute number of patients that develops such malignancies is low compared with the overall cancer rate; however, younger age of onset, higher relative risk, unique clinical presentations, and problems with early diagnosis make this a serious complication of IBD. With the exception of patients with comorbid complications, such as primary sclerosing cholangitis, the prognosis is no worse for CRCs that arise as the result of IBD compared with those that arise sporadically. The prognosis remains poor for small bowel adenocarcinomas in patients who have CD, primarily because of their advanced stage at detection. Diligent surveillance is essential for early detection and treatment of IBD-related CRCs in patients with unresected colons, long-standing or extensive disease, and in those who have early-onset CD, although pundits still question whether it significantly affects prognosis and survival. Better surveillance techniques for small bowel dysplasia or malignancy in patients who have CD is needed, especially given the poor prognosis of these patients when advanced cancers are detected. Depending on the presentation and disease diagnosis, patients have several surgical treatment options and can expect good outcomes for all. When the appropriate surgical technique is used in patients who have colon or rectal cancer, along with adjuvant chemotherapy when appropriate, prognosis and function is good; however, the experience of the surgeon can affect the prognosis for IBD-related GI cancers. Surgical therapy is based not only on general oncologic principles, but also on the surgery that is appropriate for the IBD diagnosis. Resection of the mesentery and lymphadenectomy should be performed according to oncologic principles. Postoperative survival for IBD-related CRC is good, and diligent surveillance and follow-up are critical to the patient's overall prognosis.

Postoperative maintenance therapy for inflammatory bowel disease

PURPOSE OF REVIEW

This review will highlight the knowledge gained from studies published in the year 2005 on maintenance treatment after surgery for inflammatory bowel diseases.

RECENT FINDINGS

In Crohn's disease the role of smoking in increasing the risk of relapse and recurrence after surgery is confirmed. Ornidazole seems effective in reducing endoscopic recurrence and clinical relapse after surgery. Probiotics do not appear to be effective in preventing endoscopic recurrence and clinical relapse: a controlled placebo trial showed that Lactobacillus johnsonii is not effective in preventing endoscopic recurrence. A retrospective study suggested that enteral nutrition after surgery may reduce the clinical relapse. Pathophysiological studies underlined the value of probiotics in pouchitis.

SUMMARY

In Crohn's disease postoperative maintenance treatment is disappointing. Giving up smoking is still the only effective measure. Mesalamine remains the drug that has been widely studied with large trials and meta-analysis. Encouraging results come from small trials on antibiotics. Azathioprine and 6-mercaptopurine must be evaluated in better designed controlled trials. There is no evidence in favour of probiotics as an effective therapy to prevent recurrence. Enteral nutrition after surgery is a candidate new therapy, but further controlled trials are needed. Pathophysiological studies confirm the beneficial role of probiotics in pouchitis.

Use of antibiotics in the treatment of inflammatory bowel disease

An increasing amount of evidence suggests that enteric flora may have a role in the pathogenesis of inflammatory bowel disease (IBD). Patients with IBD appear to have an altered composition of luminal bacteria that may provide the stimulus for the chronic inflammation characterizing IBD. The suspected role of bacteria in the pathogenesis of IBD provides the rationale for using agents, such as antibiotics, that alter the intestinal flora. However, there remains much uncertainty about the optimal use of antibiotics in the treatment of Crohn's disease, ulcerative colitis, and pouchitis. This article reviews the literature and presents a clinical model for the use of antibiotics in IBD.

Bowel sonography for the diagnosis and grading of postsurgical recurrence of Crohn's disease

BACKGROUND AND AIMS

Postsurgical recurrence (PSR) is common in patients with Crohn's disease (CD) who have undergone surgery. Endoscopy is crucial for the diagnosis of PSR, showing also high prognostic value. Bowel sonography (BS) is accurate for CD diagnosis, but its role in PSR detection and grading has been poorly investigated. The aim of this study was to evaluate the diagnostic accuracy of BS compared to endoscopy in the detection of PSR.

MATERIALS AND METHODS

Between March 2002 and October 2005, to gain evidence of possible PSR, we prospectively performed endoscopy and BS in 45 CD patients who had undergone previous bowel resection. Endoscopy and BS were carried out 1 year after surgery, with diagnosis and grading of PSR made in accordance with Rutgeerts. BS was considered suggestive for PSR in the presence of bowel wall thickness (BWT)>3 mm. Also, an ROC curve was constructed to define the best cutoff value for BWT to differentiate mild from severe PSR (grade 1-2 vs 3-4 of Rutgeerts).

RESULTS

Of the 45 patients with CD, 24 showed endoscopic evidence of PSR (53%). Severe endoscopic PSR was present in 16 patients (66%). Sensitivity, specificity, and positive and negative predictive values of BS were 79%, 95%, 95%, and 80%, respectively, with a sensitivity of 93% for severe PSR. On the ROC curve, a BWT>5 mm showed sensitivity, specificity, and positive and negative predictive values of 94%, 100%, 100%, and 96%, respectively, in differentiating mild from severe PSR, in remarkable agreement with endoscopy (kappa=0.90).

CONCLUSIONS

BS shows good sensitivity and high specificity for the diagnosis of PSR in CD, with a BWT>5 mm being strongly indicative of severe endoscopic PSR. Hence, BS could replace endoscopy for the diagnosis and grading of PSR in patients who comply poorly with the endoscopic examination.