The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

Tailoring therapy to the individuals of Crohn's disease

For decades, increasing incidence and prevalence of Crohn's disease (CD) have attracted more attention. Some severe complications such as perforations, fistulas, and abscesses have significantly impaired patients' quality of life. Though the emergence of biologic agents has improved disease course and prognosis to a great extent, different disease manifestations and the economic burden of disease make biologic agents not suitable for all CD patients. The ultimate goal of achieving clinical and endoscopic remission, and even transmural healing is same for every CD patient, but therapeutic decision is so difficult for individual differences. Making a personalized approach based on disease behavior, drug response and other related factors is critical for disease management. This review attempts to summarize the existing clinical trials and data for better tailoring personalized therapy of CD.

To cut or not to cut? Extended mesenteric excision during intestinal resection does not impact the postoperative recurrence nor the postoperative complications in Crohn's disease: a systematic review and meta-analysis

BACKGROUND

The mesentery might be involved in the pathogenesis of Crohn's disease (CD). As a result of scarce and conflicting data, it is debatable whether removal during intestinal resections could influence postsurgical outcome. We aimed to investigate the association between the extent of mesenteric excision during intestinal resections and postoperative complications and recurrence.

METHODS

We conducted a systematic search in five databases on 29 July 2024 for studies reporting outcomes in patients with CD who underwent intestinal resections with extended mesenteric excision (EME) compared with limited mesenteric excision (LME). Pooled odds ratios (ORs) with 95% confidence intervals (CI) were calculated using the random-effects model. We assessed the risk of bias using the ROBINS-I and RoB2 tool and evaluated the certainty of evidence according to the GRADE Working Group recommendations.

RESULTS

We retrieved data from six studies, covering 4590 patients. The pooled data showed no significant difference between EME and LME patients regarding surgical recurrence (OR 0.3; 95% CI 0.02-3.73; p = 0.176), overall postoperative complications (OR 0.78; 95% CI 0.33-1.82, p = 0.329), anastomotic leak (OR 0.76, 95% CI 0.09-6.85, p = 0.722), surgical site infection (OR 0.84, 95% CI 0.3-2.36, p = 0.539), reoperation rate (OR 1.09, 95% CI 0.33-3.58, p = 0.783), or hospitalization (MD - 0.33 (95% CI - 1.8 to 1.15, p = 0.53). Individual studies reported similar results regarding 6 months follow-up endoscopic recurrence. The certainty of evidence was very low and low, respectively.

CONCLUSION

Extended mesenteric excision is not statistically associated with improved postoperative complications or postoperative recurrence. Results should be interpreted cautiously because of the small number of studies; hence, randomized, long-term, controlled trials are needed.

Preoperative Optimization for Elective Surgery in Crohn's Disease: A Narrative Review

Crohn's disease is a chronic inflammatory bowel disease and, despite an increase in the available drug treatments, many patients will still require surgery at some point in their disease course. Stricturing and penetrating phenotypes of Crohn's disease are less likely to respond to our current medical treatment and, therefore, surgical intervention may be required. This is most commonly elective, planned surgery, thereby affording the opportunity to optimize medications, nutritional and inflammatory status, and steroid use. Poor nutritional status and previous surgery increase the risk of postoperative complications. Preoperative optimization has three main goals: reduction of postoperative complications; reduction of reoperation rates; and reduction of postoperative recurrence rates. A literature search was completed using PubMed, Embase, and Ovid using the search term "preoperative optimization in Crohn's disease", and it included both adult and pediatric studies, excluding those for perianal Crohn's disease. In this narrative review, we examine the role of nutritional intervention, medical optimization pre and postoperatively, and the role of personalized prehabilitation in the reduction of postoperative complications. We demonstrate that these may all yield better postoperative outcomes for patients with Crohn's disease undergoing elective surgery, although the evidence is somewhat limited and there is a requirement for more prospective randomized controlled trials to implement their role into standard practice or guidelines.

The fate of the rectum in ulcerative colitis at index surgery and beyond-a contemporary cohort

PURPOSE

Proctectomy is frequently deferred at index colectomy for ulcerative colitis due to acuity or immunosuppressive treatments. The retained rectum remains symptomatic in over 50% with associated cancer risk. Management options include index or delayed proctectomy with or without restoration of continuity or surveillance. Comparative studies of perioperative outcomes and reasons for retaining the rectum are lacking.

METHODS

This 13-year retrospective cohort assesses the fate of the rectum in 168 ulcerative colitis patients by analysing index proctectomy, staged proctectomy and retained rectal remnant determinants and outcomes. The primary outcome was the fate of the rectum. Secondary analysis included perioperative morbidity, length of stay and decision-making determinants.

RESULTS

Proctectomy was performed in 69% of patients, with 16.1% at index surgery. Restorative surgery rate was 44%. Index proctectomy patients were older (54 vs 37 years, p < 0.01), more co-morbid (59.3% vs 38.2%, p = 0.04) and likely to have elective surgery (81.5% vs 21.3%, p < 0.01) or neoplasia (33.3% vs 1.1%, p < 0.01). Outcomes after staged proctectomy were comparable, with age influencing restoration of continuity (33.5 vs 46 years, p < 0.01). Younger patients were indecisive on proctectomy, while those opting for endoscopic surveillance were older (median 65 years, p < 0.01), had more complications (64.3%, p = 0.23) and prolonged hospitalisation (median 15 days, p = 0.02) at colectomy.

CONCLUSIONS

Index proctocolectomy for ulcerative colitis is infrequently performed. Perioperative outcomes of restorative and non-restorative staged proctectomy are comparable. Perioperative experience at colectomy may influence patient decisions regarding future management of their rectum.

Endoscopy for Altered Anatomy in Inflammatory Bowel Disease

A significant proportion of patients with Crohn's disease or ulcerative colitis will ultimately necessitate surgical interventions, despite advances in diagnosis, medical therapy, and endoscopic interventions. These surgeries lead to substantial alterations in bowel anatomy. The present review aims to emphasize the key role of conducting a comprehensive endoscopic evaluation of both anatomic landmarks and endoscopic features for accurate clinical interpretation, thereby impacting decisions regarding medical or endoscopic interventions.

Appraisal of current surgical guidelines for inflammatory bowel disease using the AGREE-S instrument: A scoping review

AIM

Guidelines play a crucial role in improving patient care by providing clinicians with up to date evidence-based recommendations. A vast number of guidelines exist on the surgical management of inflammatory bowel disease (IBD). The aim of this scoping review was to identify current surgical IBD guidelines, assess their quality and identify areas of variation between the existing guidelines.

METHOD

A systematic search of the literature from January 2008 to September 2023 was conducted. After identifying eligible guidelines, they were assessed for quality using the Appraisal of Guidelines for Research and Evaluation for Surgical Interventions (AGREE-S) instrument. Data were extracted on descriptive guideline characteristics and recommendations.

RESULTS

Fifteen guidelines were identified globally. Most guidelines were published between 2011 and 2023, with six focusing solely on Crohn's disease, five on ulcerative colitis and four on both. Six guidelines focused exclusively on surgical management, while nine contained both medical and surgical recommendations. The overall mean AGREE-S score was 59%, with more recent guidelines scoring higher.

CONCLUSIONS

The quality of IBD surgical guidelines varies considerably. High-quality, collaborative, international guidelines are needed to reduce duplication and ensure consistent, evidence-based surgical care for IBD patients worldwide. Future guideline development should adhere to the AGREE-S criteria to enhance methodological rigour and transparency.

Catastrophic outcome following misidentification of bowel anatomy during Hartmann's reversal: A case report and technical considerations

BACKGROUND

Reversal of Hartmann's procedure is a complex surgery with potential complications. This case report describes a rare and severe complication following an attempted reversal.

CASE PRESENTATION

A 53-year-old male who had undergone a Hartmann's procedure for non-metastatic sigmoid colon cancer presented with bowel obstruction 10 days after attempted reversal surgery at another hospital. Imaging studies suggested an entero-colic fistula. Emergency laparotomy revealed dense adhesions and multiple bowel injuries. The procedure was terminated, and controlled fistulae were created.

MANAGEMENT AND OUTCOME

The patient required two months of intensive care. A subsequent surgery excised the fistulae and restored intestinal continuity, leaving the patient with an end colostomy and approximately 120 cm of ileum.

CONCLUSION

This case highlights the potential risks of Hartmann's reversal and emphasizes the importance of proper patient selection, timing, and surgical expertise. It underscores the need for thorough preoperative evaluation and preparation when attempting such complex surgeries.

Incidence of rectal cancer after colectomy for inflammatory bowel disease: nationwide study

BACKGROUND

Inflammatory bowel disease increases the risk of colorectal neoplasia. A particular problem arises in patients who have undergone subtotal colectomy leaving a rectal remnant. The risk of future rectal cancer must be accurately estimated and weighed against the risks of further surgery or surveillance. The aim of this study was to estimate the 10-year cumulative incidence of rectal cancer in such patients.

METHODS

A nationwide study using England's hospital administrative data was performed. A cohort of patients undergoing subtotal colectomy between April 2002 and March 2014 was identified. A competing risks survival analysis was performed to calculate the cumulative incidence of rectal cancer. The effect of the COVID-19 pandemic on endoscopic surveillance was investigated using time-trend analysis.

RESULTS

A total of 8120 patients were included and 61 patients (0.8%) were diagnosed with cancer. The cumulative incidence of rectal cancer was 0.26% (95% c.i. 0.17% to 0.39%), 0.49% (95% c.i. 0.36% to 0.68%), and 0.77% (95% c.i. 0.57% to 1.02%) at 5, 10, and 15 years respectively. A previous diagnosis of colonic dysplasia (HR 3.34, 95% c.i. 1.01 to 10.97; P = 0.047), primary sclerosing cholangitis (HR 5.42, 95% c.i. 1.34 to 21.85; P = 0.018), and elective colectomy (HR 1.83, 95% c.i. 1.11 to 3.02; P = 0.018) was associated with an increased incidence of rectal cancer. Regarding endoscopic surveillance, there was a 43% decline in endoscopic procedures performed in 2020 (333 procedures) compared with 2019 (585 procedures).

CONCLUSION

The incidence of rectal cancer after subtotal colectomy is low. Asymptomatic patients without evidence of rectal dysplasia should be carefully counselled on the possible benefits and risks of prophylactic proctectomy.

Temporary diverting loop ileostomy in Crohn's disease surgery; indications and outcome

INTRODUCTION

Crohn's disease can present with complex surgical pathologies, posing a significant risk of morbidity and mortality for patients. The implementation of a loop ileostomy for selected patients may help minimize associated risks.

METHODS

In this retrospective cohort study, we investigated the utilization of temporary fecal diversion through the creation of a loop ileostomy in Crohn's surgery. Closure of all ostomies involved a hand-sewn single-layer technique. We then conducted bivariate analysis on 30-day outcomes for closures, focusing on favorable recovery defined as the restoration of bowel continuity without the occurrence of two challenges in recovery: newly developed organ dysfunction or the necessity for reoperation.

RESULTS

In total, 168 patients were included. The median age of the patients was 38 years (IQR 27-51). The most common indication for a loop ostomy was peritonitis (49%). After ileostomy closure, 163 patients (97%) achieved favorable recovery, while five encountered challenges; four (2.4%) underwent abdominal surgery, and one (0.6%) developed acute renal failure requiring dialysis. Two patients (1.2%) had a re-creation of ileostomy. Patients encountering challenges were older (56 [IQR 41-61] vs. 37 [IQR 27-50]; p 0.039) and more often required secondary intention wound healing (40% vs. 6.7%; p 0.049) and postoperative parenteral nutrition following their index surgery (83% vs. 26%; p 0.006).

CONCLUSION

Selectively staging the Crohn's disease operations with a loop ileostomy is a reliable practice with low morbidity and high restoration rates of bowel continuity. Our hand-sewn single-layer technique proves effective in achieving successful surgical recovery.

European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula

AIM

The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology.

METHODS

Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG.

RESULTS

In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations.

CONCLUSION

This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.

Anastomotic Configuration and Temporary Diverting Ileostomy Do Not Increase Risk of Anastomotic Stricture in Postoperative Crohn's Disease

INTRODUCTION

Surgical management of Crohn's disease (CD) is common. Postoperative complications include anastomotic stricturing (AS). The natural history and risk factors for AS have not been elucidated.

METHODS

A retrospective cohort study of patients with CD who underwent ileocolonic resection (ICR) with ≥1 postoperative ileocolonoscopy between 2009 and 2020. Postoperative ileocolonoscopies with corresponding cross-sectional imaging were evaluated for evidence of AS without neoterminal ileal extension. Severity of AS and endoscopic intervention at time of detection were collected. Primary outcome was development of AS. Secondary outcome was time to AS detection.

RESULTS

A total of 602 adult patients with CD underwent ICR with postoperative ileocolonoscopy. Of these, 426 had primary anastomosis, and 136 had temporary diversion at time of ICR. Anastomotic configuration consisted of 308 side-to-side, 148 end-to-side, and 136 end-to-end. One hundred ten (18.3%) patients developed AS with median time of 3.2 years to AS detection. AS severity at time of detection was associated with need for repeat surgical resection for AS. On multivariable Cox proportional hazard regression, anastomotic configuration and temporary diversion were not associated with risk of or time to AS. Preoperative stricturing disease was associated with decreased time to AS (adjusted hazard ratio 1.8; P = 0.049). Endoscopic ileal recurrence before AS was not associated with subsequent AS detection.

DISCUSSION

AS is a relatively common postoperative CD complication. Patients with previous stricturing disease behavior are at increased risk of AS. Anastomotic configuration, temporary diversion, and ileal CD recurrence do not increase risk of AS. Early detection and intervention for AS may help prevent progression to repeat ICR.

A call for clarity: a scoping review of predictors of poor outcome after emergency abdominal surgery for inflammatory bowel disease

AIM

The medical management of inflammatory bowel disease (IBD) is rapidly progressing; however, many patients with the disease still require surgery. Often this is done as an emergency. Initiatives such as the National Emergency Laparotomy Audit have shown how evidence-based emergency surgery improves outcomes for the patient. The aim of this scoping review is to describe the current evidence base on risk stratification in emergency abdominal surgery for IBD.

METHODS

A literature search, abstract and full paper screening resulted in 17 articles representing 63 472 patients from seven countries.

RESULTS

It is likely that age, the American Society of Anesthesiologists grade, comorbidity and organ dysfunction play a similar role in risk stratification in IBD patients as in other emergency abdominal surgery cohorts. However, the reporting of what is considered an IBD emergency is variable. Six studies include clear definitions of emergency in our study. The range of what is considered an emergency is within 12 h of admission to any time within an unplanned admission.

CONCLUSION

To have data driven, evidence-based emergency surgical practice in IBD we need consistency of reporting, including the definitions of emergency and urgency. Core descriptor sets in IBD would be valuable.

DECIDE: Delphi Expert Consensus Statement on Inflammatory Bowel Disease Dysplasia Shared Management Decision-Making

BACKGROUND AND AIMS

Inflammatory bowel disease colitis-associated dysplasia is managed with either enhanced surveillance and endoscopic resection or prophylactic surgery. The rate of progression to cancer after a dysplasia diagnosis remains uncertain in many cases and patients have high thresholds for accepting proctocolectomy. Individualised discussion of management options is encouraged to take place between patients and their multidisciplinary teams for best outcomes. We aimed to develop a toolkit to support a structured, multidisciplinary and shared decision-making approach to discussions about dysplasia management options between clinicians and their patients.

METHODS

Evidence from systematic literature reviews, mixed-methods studies conducted with key stakeholders, and decision-making expert recommendations were consolidated to draft consensus statements by the DECIDE steering group. These were then subjected to an international, multidisciplinary modified electronic Delphi process until an a priori threshold of 80% agreement was achieved to establish consensus for each statement.

RESULTS

In all, 31 members [15 gastroenterologists, 14 colorectal surgeons and two nurse specialists] from nine countries formed the Delphi panel. We present the 18 consensus statements generated after two iterative rounds of anonymous voting.

CONCLUSIONS

By consolidating evidence for best practice using literature review and key stakeholder and decision-making expert consultation, we have developed international consensus recommendations to support health care professionals counselling patients on the management of high cancer risk colitis-associated dysplasia. The final toolkit includes clinician and patient decision aids to facilitate shared decision-making.

Liver Transplantation for Primary Sclerosing Cholangitis (PSC) With or Without Inflammatory Bowel Disease (IBD)-A European Society of Organ Transplantation (ESOT) Consensus Statement

Primary sclerosing cholangitis (PSC) is the classical hepatobiliary manifestation of inflammatory bowel disease (IBD) and a lead indication for liver transplantation (LT) in the western world. In this article, we present a Consensus Statement on LT practice, developed by a dedicated Guidelines' Taskforce of the European Society of Organ Transplantation (ESOT). The overarching goal is to provide practical guidance on commonly debated topics, including indications and timing of LT, management of bile duct stenosis in patients on the transplant waiting list, technical aspects of transplantation, immunosuppressive strategies post-transplant, timing and extension of intestinal resection and futility criteria for re-transplantation.

The incidence of malignancy in the residual rectum of IBD patients after colectomy: a systematic review and meta-analysis

BACKGROUND

Patients with inflammatory bowel disease (IBD) who have had a total colectomy remain with their rectum in situ, and are therefore at risk of rectal carcinoma. It is not clear how high the incidence of rectal cancer is in this cohort. The primary objective of this meta-analysis was to estimate the incidence of rectal cancer in patients with ulcerative colitis or Crohn's disease who have undergone colectomy but have a residual rectum, and to identify the risk factors for its development. In doing so, we explore the current recommendations for screening processes for these patients.

METHODS

A systematic review of the literature was performed. Five databases (Medline, Embase, Pubmed, Cochrane Library and Scopus) were searched from inception to 29 October 2021, to identify studies adhering to the population, intervention, control and outcomes (PICO) criteria. The included studies were critically appraised, and the relevant data was extracted. Cancer incidence was estimated from the reported information. Risk stratification was analysed using RevMan. A narrative approach was undertaken for the exploration of the existing screening guidelines.

RESULTS

Data from 23 of the 24 identified studies was suitable for analysis. The pooled incidence of rectal carcinoma was calculated to be 1.3%. Subgroup analysis showed an incidence of 0.7% and 3.2% for patients with a de-functioned rectal stump and ileorectal anastomosis, respectively. Patients with a history of a colorectal carcinoma were more likely to have a subsequent diagnosis of rectal carcinoma (RR 7.2, 95% CI 2.4-21.1). Patients with previous colorectal dysplasia were also at higher risk (RR 5.1, 95% CI 3.1-8.2). No universal standardised guidance regarding screening for this cohort could be identified in the available literature.

CONCLUSIONS

The overall risk of malignancy was estimated to be 1.3%, which is lower than previously reported. There is a need for clear and standardised screening guidance for this group of patients.

Complementary and alternative medicine mention and recommendations in inflammatory bowel disease guidelines: systematic review and assessment using AGREE II

BACKGROUND

Many patients with inflammatory bowel disease (IBD) use complementary and alternative medicine (CAM) for disease management. There is, however, a communication gap between patients and healthcare professionals regarding CAM use, where patients are hesitant to disclose CAM use to providers. The purpose of this study was to identify the quantity and assess the quality of CAM recommendations in IBD clinical practice guidelines (CPGs) using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

METHODS

MEDLINE, EMBASE, and CINAHL were systematically searched from 2011 to 2022 to find CPGs for the treatment and/or management of IBD. The Guidelines International Network (GIN) and National Center for Complementary and Integrative Health (NCCIH) websites were also searched. Eligible CPGs were assessed using the AGREE II instrument.

RESULTS

Nineteen CPGs made CAM recommendations for IBD and were included in this review. Average scaled domain percentages of CPGs were as follows (overall CPG, CAM section): scope and purpose (91.5%, 91.5%), clarity of presentation (90.3%, 64.0%), editorial independence (57.0%, 57.0%), stakeholder involvement (56.7%, 27.8%), rigour of development (54.7%, 45.9%), and applicability (14.6%, 2.1%).

CONCLUSIONS

The majority of CPGs with CAM recommendations were of low quality and their CAM sections scored substantially lower relative to other therapies in the overall CPG. In future updates, CPGs with low scaled-domain percentages could be improved in accordance with AGREE II and other guideline development resources. Further research investigating how CAM therapies can best be incorporated into IBD CPGs is warranted.

The ENiGMA CODE collaborators. Development of a core descriptor set for Crohn's anal fistula

AIM

Crohn's anal fistula (CAF) is a complex condition, with no agreement on which patient characteristics should be routinely reported in studies. The aim of this study was to develop a core descriptor set of key patient characteristics for reporting in all CAF research.

METHOD

Candidate descriptors were generated from published literature and stakeholder suggestions. Colorectal surgeons, gastroenterologists and specialist nurses in inflammatory bowel disease took part in three rounds of an international modified Delphi process using nine-point Likert scales to rank the importance of descriptors. Feedback was provided between rounds to allow refinement of the next ratings. Patterns in descriptor voting were assessed using principal component analysis (PCA). Resulting PCA groups were used to organize items in rounds two and three. Consensus descriptors were submitted to a patient panel for feedback. Items meeting predetermined thresholds were included in the final set and ratified at the consensus meeting.

RESULTS

One hundred and thirty three respondents from 22 countries completed round one, of whom 67.0% completed round three. Ninety seven descriptors were rated across three rounds in 11 PCA-based groups. Forty descriptors were shortlisted. The consensus meeting ratified a core descriptor set of 37 descriptors within six domains: fistula anatomy, current disease activity and phenotype, risk factors, medical interventions for CAF, surgical interventions for CAF, and patient symptoms and impact on quality of life.

CONCLUSION

The core descriptor set proposed for all future CAF research reflects characteristics important to gastroenterologists and surgeons. This might aid transparent reporting in future studies.

Impact of the body mass index on the retention of the anorectal mucosa after double-stapled ileal pouch-anal anastomosis for ulcerative colitis

BACKGROUND

Double-stapled ileal pouch-anal anastomosis (DS-IPAA) is easy to construct and has a good functional outcome in patients with ulcerative colitis (UC). However, retention of the anorectal mucosa may lead to a subsequent risk of inflammation and neoplasia. This study aimed to identify factors associated with the retention of a large amount of anorectal mucosa after DS-IPAA.

METHODS

The medical records of 163 patients who had undergone one-stage total proctocolectomy and DS-IPAA for UC between 2007 and 2020 were retrospectively reviewed. The patients were divided into two groups according to the length of the retained mucosa. The high anastomosis group was defined as having a retained mucosal length of ≥ 30 mm in the anterior or posterior wall. Clinical factors were compared between the high and low anastomosis groups.

RESULTS

The high anastomosis group showed a significantly higher body mass index (BMI) (high vs. low: 23.2 vs. 19.0), longer operation time (304 vs. 263) and greater blood loss (357 vs. 240). In the multivariate analysis, high BMI was the only factor significantly associated with high anastomosis (odds ratio 1.32). There was a positive correlation between BMI and the length of the retained mucosa.

CONCLUSIONS

In DS-IPAA, BMI showed the strongest association with the retention of a large amount of the anorectal mucosa. In high BMI patients, although the risk of inability of anastomosis is little than that of IPAA with mucosectomy, the possible retention of a large amount of mucosa should be considered.

Perioperative optimization of Crohn's disease

Crohn's disease (CD) is a chronic inflammatory disease mainly affecting the gastrointestinal tract. With the increased availability of modalities in the last two decades, the treatment of CD has advanced remarkably. Although medical treatment is the mainstay of therapy, most patients require surgery during the course of their illness, especially those who experience complications. Nutritional optimization and ERAS implementation are crucial for patients with CD who require surgical intervention to reduce postoperative complications. The increased surgical risk was found to be associated with the use of corticosteroids, but the association of surgical risk with immunomodulators, biologic therapy, such as anti-TNF mediations, anti-integrin medications, and anti-IL 12/23 was low in certainty. Decisions about preoperative medication must be made on an individual case-dependent basis. Preoperative imaging studies can assist in the planning of appropriate surgical strategies and approaches. However, patients must be informed of any alterations to their treatment. In summary, the management of perioperative medications and surgery-related decision-making should be individualized and patient-centered based on a multidisciplinary approach.

Patient preferences and current practice for adults with steroid-resistant ulcerative colitis: POPSTER mixed-methods study

BACKGROUND

Corticosteroids are a mainstay of the treatment of moderately severe relapses of ulcerative colitis, yet almost 50% of patients do not respond fully to these and risk prolonged steroid use and side effects. There is a lack of clarity about the definitions of steroid resistance, the optimum choice of treatment, and patient and health-care professional treatment preferences.

OBJECTIVES

The overall aim of this research was to understand how steroid-resistant ulcerative colitis is managed in adult secondary care and how current practice compares with patient and health-care professional preferences.

DESIGN

A mixed-methods study, including an online survey, qualitative interviews and discrete choice experiments.

SETTING

NHS inflammatory bowel disease services in the UK.

PARTICIPANTS

Adults with ulcerative colitis and health-care professionals treating inflammatory bowel disease.

RESULTS

We carried out a survey of health-care professionals (n = 168), qualitative interviews with health-care professionals (n = 20) and patients (n = 33), discrete choice experiments with health-care professionals (n = 116) and patients (n = 115), and a multistakeholder workshop (n = 9). The interviews with and survey of health-care professionals showed that most health-care professionals define steroid resistance as an incomplete response to 40 mg per day of prednisolone after 2 weeks. The survey also found that anti-tumour necrosis factor drugs (particularly infliximab) are the most frequently offered drugs across most steroid-resistant (and steroid-dependent) patient scenarios, but they are less frequently offered to thiopurine-naive patients. Patient interviews identified several factors influencing their treatment choices, including effectiveness of treatment, recommendations from health-care professionals, route of administration and side effects. Over time, depending on the severity and duration of symptoms and, crucially, as medical treatment options become exhausted, patients are willing to try alternative treatments and, eventually, to undergo surgery. The discrete choice experiments found that the probability of remission and of side effects strongly influences the treatment choices of both patients and health-care professionals. Patients are less likely to choose a treatment that takes longer to improve symptoms. Health-care professionals are willing to make difficult compromises by tolerating greater safety risks in exchange for therapeutic benefits. The treatments ranked most positively by patients were infliximab and tofacitinib (each preferred by 38% of patients), and the predicted probability of uptake by health-care professionals was greatest for infliximab (62%).

LIMITATIONS

The survey and the discrete choice experiments with patients and health-care professionals are limited by their relatively small sample sizes. The qualitative studies are subject to selection bias. The timing of the different substudies, both before and during the COVID-19 pandemic, is a potential limitation.

CONCLUSIONS

We have identified factors influencing treatment decisions for steroid-resistant ulcerative colitis and the characteristics to consider when choosing treatments to evaluate in future randomised controlled trials. The findings may be used to improve discussions between patients and health-care professionals when they review treatment options for steroid-resistant ulcerative colitis.

FUTURE WORK

This research highlights the need for consensus work to establish an agreed definition of steroid resistance in ulcerative colitis and a greater understanding of the optimal use of tofacitinib and surgery for this patient group. A randomised controlled trial comparing infliximab with tofacitinib is also recommended.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 41. See the NIHR Journals Library website for further project information.

Pregnancy outcomes after stoma surgery for inflammatory bowel disease: The results of a retrospective multicentre audit

AIM

There is a paucity of data on pregnancies in women with stomas due to inflammatory bowel disease (IBD). The aim of this study was to assess stoma, IBD, obstetric and neonatal outcomes in pregnant patients with IBD and a stoma.

METHOD

Multicentre retrospective audit in 15 UK hospitals. Pregnancy, stoma and neonatal outcomes were elicited from routinely collected hospital records.

RESULTS

Data on 82 pregnancies from 77 patients (mean age 31.4 years, 60.9% Crohn's disease, 35.4% ulcerative colitis, 3.6% IBD-U) were included. Stoma types included ileostomy in 72 (88%) and colostomy in 10 (12%) women. There was one reported miscarriage, one still birth and 80 live births. Delivery occurred in 58 cases by caesarean section (CS), of which 44 were performed electively and 14 as emergency CS. The overall CS rate was 73%. Premature delivery before week 37 occurred in 19% and birth weight <2,500 g in 17%. Significant stoma related complications occurred during 20 (24%) pregnancies and included stoma prolapse in nine cases (2 required surgery), parastomal hernias in three cases (2 required surgery) and small bowel obstructions in seven cases (3 required surgery).

CONCLUSIONS

Pregnancy for women who previously had stoma formation for IBD is associated with higher rates of caesarean section and stoma complications. Future prospective studies should capture data, including patient reported outcomes, to gather a full picture on the impact of pregnancy after stoma surgery for IBD.

State-of-the-art surgery for Crohn's disease: Part II-colonic Crohn's disease and associated neoplasms

Despite advances in medical therapy, surgery continues to play a vital role in the management of Crohn's disease and its complications. Continuing from Part I of this series (small intestine/ileal disease), we focus next on colonic Crohn's disease and associated neoplasms. We will first review the surgical management of medical-refractory Crohn's colitis and its complications and then examine cancer risk, surveillance, and surgical management of Crohn's-associated colorectal dysplasia and malignancy. We conclude with a discussion of restoration of gastrointestinal continuity following colonic surgery for Crohn's disease.

Surgical Planning in Penetrating Abdominal Crohn's Disease

Crohn's disease (CD) is increasing globally, and the disease location and behavior are changing toward more colonic as well as inflammatory behavior. Surgery was previously mainly performed due to ileal/ileocaecal location and stricturing behavior, why many anticipate the surgical load to decrease. There are, however, the same time data showing an increasing complexity among patients at the time of surgery with an increasing number of patients with the abdominal perforating disease, induced by the disease itself, at the time of surgery and thus a more complex surgery as well as the post-operative outcome. The other major cause of abdominal penetrating CD is secondary to surgical complications, e.g., anastomotic dehiscence or inadvertent enterotomies. To improve the care for patients with penetrating abdominal CD in general, and in the peri-operative phase in particular, the use of multidisciplinary team discussions is essential. In this study, we will try to give an overview of penetrating abdominal CD today and how this situation may be handled. Proper surgical planning will decrease the risk of surgically induced penetrating disease and improve the outcome when penetrating disease is already established. It is important to evaluate patients prior to surgery and optimize them with enteral nutrition (or parenteral if enteral nutrition is ineffective) and treat abdominal sepsis with drainage and antibiotics.

Prevalence, diagnosis, and surgical management of complex ileocolic-duodenal fistulas in Crohn's disease

BACKGROUND

The aim of the present study was to review the prevalence and surgical management of patients with Crohn's disease (CD) complicated by ileocolic-duodenal fistulas (ICDF).

METHODS

We performed a retrospective chart review of CD patients who underwent surgical takedown and repair of ICDF during January 2011-December 2021 at two inflammatory bowel disease referral centers.

RESULTS

We identified 17 patients with ICDF (1.3%) out of 1283 CD patients who underwent abdominal surgery. Median age was 42 (20-71) years, 13 patients were male (76%) and median body mass index was 22.7 (18.4-30.3) kg/m². Four patients (24%) were diagnosed preoperatively and only 2 (12%) were operated on for ICDF-related symptoms. The most common procedure was ileocolic resection (13 patients, 76%) including 4 repeat ileocolic resections (24%). The duodenal defect was primarily repaired in all patients with no re-fistulization or duodenal stenosis, regardless of the repair technique. A laparoscopic approach was attempted in the majority of patients (14 patients, 82%); however, only 5 (30%) were laparoscopically completed. The overall postoperative complication rate was 65% including major complications in 3 patients (18%) and 2 patients (12%) who required surgical re-intervention for abdominal wall dehiscence and postoperative bleeding. Preoperative nutritional optimization was performed in 9 patients (53%) due to malnutrition. These patients had significantly less intra-operative blood loss (485 vs 183 ml, p = 0.05), and a significantly reduced length of stay (18 vs 8 days, p = 0.05).

CONCLUSION

ICDF is a rare manifestation of CD which may go unrecognized despite the implementation of a comprehensive preoperative evaluation. Although laparoscopic management of ICDF may be technically feasible, it is associated with a high conversion rate. Preoperative nutritional optimization may be beneficial in improving surgical outcomes in this select group of patients.

Surgical Management of Small Bowel Crohn's Disease

Crohn's disease in the small bowel could present itself as an inflammatory stricture, a fibrotic stricture as penetrating disease or a combination of both. It is pertinent to differentiate the disease process as well as its extent to effectively manage the disease. Currently, a combination of medical and surgical therapies forms part of the treatment plan while the debate of which therapy is better continues. In managing the strictures, identification of the disease process through imaging plays a pivotal role as inflammatory strictures respond to anti-tumor necrosis factor (TNF) and biological agents, while fibrotic strictures require endoscopic or surgical intervention. Recent evidence suggests a larger role for surgical excision, particularly in ileocolic disease, while achieving a balance between disease clearance and bowel preservation. Several adaptations to the surgical technique, such as wide mesenteric excision, side to side or Kono-S anastomosis, and long-term metronidazole therapy, are being undertaken even though their absolute benefit is yet to be determined. Penetrating disease requires a broader multidisciplinary approach with a particular focus on nutrition, skincare, and intestinal failure management. The current guidance directs toward early surgical intervention for penetrating disease when feasible. Accurate preoperative imaging, medical management of active diseases, and surgical decision-making based on experience and evidence play a key role in success.

Minimally Invasive Surgical Approach to Toxic Colitis

BACKGROUND

We aimed to compare outcomes of surgical treatments of toxic colitis (infectious/inflammatory/ischemic) by the extent of colectomy (partial vs total colectomy) and different surgical approaches (minimally invasive surgery (MIS) vs open).

METHODS

Multivariate analysis using logistic regression was used to investigate outcomes of patients with toxic colitis who underwent emergent colectomy during 2012-2019 by surgical approach and the extent of resection using NSQIP database.

RESULTS

Overall, 2,104 adult patients underwent emergent colectomy for toxic colitis within NSQIP database during 2012-2019. Overall, 1,578 (75.4%) underwent total colectomy with colostomy, 486 (23.2%) underwent partial colectomy with colostomy, and 28 (1.3%) underwent partial colectomy with anastomosis. Overall, 198 (9.4%) of procedures were minimally invasive (MIS) with a 40.1% conversion rate to open. Thirty days mortality and morbidity of the patients were 31 and 86%, respectively. There was no significant difference in mortality of partial colectomy without anastomosis compared to total colectomy (P = .86) and partial colectomy with anastomosis (P = .64). Anastomosis was associated with 32.3% anastomosis leakage and 17.9% reoperation. MIS approach was associated with significant decrease in mortality (8.6 vs 33.3%, AOR: .35, P < .01) and morbidity (62.9 vs 87.8%, AOR: .49, P < .01) of patients.

CONCLUSION

Patients with toxic colitis undergoing surgical treatment have high mortality and morbidity. An MIS approach when possible is significantly associated with decreased morbidity and mortality of patients. There was no significant difference in outcomes seen when extending the resection in multivariate analysis. Anastomosis is associated with a high anastomosis leakage and need for reoperation risk.

A contemporary series of surgical outcomes following subtotal colectomy and/or completion proctectomy for management of inflammatory bowel disease

BACKGROUND

The main indications for emergency subtotal colectomy (SC) include management of toxic colitis, refractory haemorrhage and/or perforation. Alternatively, elective surgery is performed for those refractory to medical therapy or with evidence of multifocal dysplasia. Overall, the annual incidence of SC has fallen since the introduction of biologic therapies and we aimed to review our current practices.

METHODS

A retrospective review of inflammatory bowel disease (IBD) patients undergoing subtotal colectomy between 2013 and 2020 was performed. Medical records, operative notes, discharge summaries, histopathology reports and other supporting documents were reviewed. Indication for surgery, management of the rectum (i.e. maintenance of rectal stump, progression to completion proctectomy or IPAA formation) associated morbidity (Clavien-Dindo classification) and length of hospital stay were examined.

RESULTS

Fifty-six IBD patients underwent a subtotal colectomy. Twenty-five patients (UC 14, Crohn's 11) had an elective procedure, and 31 patients (UC 19 Crohn's 12) had an emergency/semi-urgent procedure. Interestingly, 80% (n = 25) of the emergency cohort and 68% (n = 17) of the elective cohort had a laparoscopic resection. Major morbidity (Clavien-Dindo > 2) was higher among the emergency group (39% vs. 24%). Deep surgical site infection was the commonest morbidity (13%) in the emergency group, while superficial surgical site infection was commonest in the elective cohort (20%). Overall, there was no difference in surgical re-intervention rate (13% vs 12%), and there were no perioperative mortalities. Median post-operative length of stay was shorter in the elective cohort (9 versus 13 days).

CONCLUSION

A significant proportion of IBD patients still require semi-urgent/emergency colectomy, which is associated with considerable length of stay and morbidity. The results of our study provide real-world outcomes to help counsel patients on expected outcomes.

What's New in the Postoperative Management of Crohn's Disease?

Patients with Crohn's disease (CD) often require surgical resection due to complications, such as strictures and abscesses, or disease refractory to medical therapy. To understand the evolving management of patients with CD after surgery, we outline the risk factors for postoperative recurrence, advances in postoperative endoscopic evaluation and characterization of recurrence, noninvasive methods of assessing postoperative recurrence, use of postoperative prophylactic medical therapy including newer biologics, and novel surgical methods to reduce postoperative recurrence. The Rutgeerts score (RS) was developed to predict progression of disease based on endoscopic appearance postoperatively and to guide medical therapy. However, this scoring system groups ileal and anastomotic lesions into the same category. A modified RS was developed to separate lesions isolated to the anastomosis and those in the neo-terminal ileum to further understand the role of anastomotic lesions in CD progression. Additional scoring systems have also been evaluated to better understand these differences. In addition, noninvasive diagnostic methods, such as small bowel ultrasound, have high sensitivity and specificity for the detection of postoperative recurrence and are being evaluated as independent methods of assessment. Studies have also shown a reduction in endoscopic recurrence with postoperative anti-TNFα therapy. However, preoperative exposure to anti-TNFα therapy may impact postoperative response to these medications, and therefore, determining optimal postoperative prophylaxis strategy for biologic-experienced patients requires further exploration. Lastly, new surgical modalities to reduce postoperative recurrence are currently being investigated with preliminary data suggesting that an antimesenteric functional end-to-end anastomosis (Kono-S) may decrease postoperative recurrence.

Diversion proctocolitis and the problem of the forgotten rectum in inflammatory bowel diseases: A systematic review

Background and aims

Diversion proctocolitis (DP) is a non‐specific mucosal inflammation arising in the defunctionalized colon and/or rectum following faecal diversion (colostomy, ileostomy). Differential diagnosis of DP from the underlying disease in patients with inflammatory bowel diseases (IBD) is often unclear. As a result, it might be difficult to undertake any specific treatment. We aimed to systematically review the literature evidence on DP in IBD patients.

Methods

For this qualitative systematic review, we searched PubMed, EMBASE and Scopus to identify all studies published until July 2021 including IBD patients affected by DP.

Results

Overall, 37 papers published between 1982 and 2021 were included. A total of 1.211 IBD patients were included: 613 UC (50.6%), 524 CD (43.3%), 66 IBD‐unclassified (IBD‐U) (5.4%), 8 unspecified patients (0.7%). Most patients with DP are asymptomatic, although inflammation is detectable in almost all patients with a rectal stump. Reduced short‐chain fatty acids and an altered microbiome, may trigger mucosal inflammation and have been proposed as causing factors. An increased risk of developing cancer on DP has been reported in patients with a history of previous dysplasia/cancer.

Conclusions

The etiopathogenesis of DP is still unknown. The efficacy of mesalamine, corticosteroids or short‐chain fatty acids has not been proven by randomized trials yet. Since the incidence of cancer of the rectal stump can reach 4.5 per 1.000 diverted patients‐year, IBD patients undergoing subtotal colectomy with end‐ileostomy should undergo close endoscopic surveillance, being eventually counseled for surgery with or without the restoration of the intestinal continuity.

Rectal Cancer Incidence is Low Following Rectal Diversion or Subtotal Colectomy for IBD: Results of a Population-based Study

BACKGROUND AND AIMS

Following subtotal colectomy or diversion for medically refractory inflammatory bowel disease [IBD], completion proctectomy has been recommended to reduce the risk of rectal cancer. However, this recommendation is based on low-quality evidence. Our objectives were to estimate the cumulative incidence of rectal cancer and evaluate if surveillance endoscopy reduces the risk of rectal cancer.

METHODS

We performed a population-based retrospective cohort study in Ontario, Canada, of all patients undergoing either subtotal colectomy or diversion for medically refractory IBD over 1991-2015. We excluded patients with a previous history of colorectal cancer or previous rectal resection, and those with <1 year of observation. We calculated the rate of incident rectal cancer using a competing risks model, and evaluated the effect of surveillance endoscopy on the rate of rectal cancer.

RESULTS

In all, 3700 patients were included with a median follow-up of 4.3 years. Of this cohort, 47% underwent rectal resection or restoration of gastrointestinal [GI] continuity during the observation period; 40 patients were diagnosed with rectal cancer, with a cumulative incidence of rectal cancer of 0.81% (95% confidence interval [CI] 0.53%, 1.20%) and 1.86% [95% CI 1.29%, 2.61%] at 10 and 20 years, respectively. Surveillance endoscopy was associated with a lower rate of rectal cancer (subhazard ratio [sHR] 0.37, 95% CI 0.16, 0.82, p = 0.014].

CONCLUSIONS

Among patients with a retained rectum following surgery for IBD, the risk of rectal cancer is low and appears to be lower when surveillance endoscopy is performed. Expectant management with surveillance endoscopy may be a reasonable alternative to completion proctectomy in selected patients.

Comparison between oxaliplatin therapy and capecitabine monotherapy for high-risk stage II-III elderly colon cancer patients

PURPOSE

45% of colon cancer patients are elderly, yet they are often deviated from standard cancer management. The MOSAIC trial favored FOLFOX over FL with superior oncologic outcomes; however, which regimen is most beneficial in elderly population remains unclear. This study aimed to compare the efficacy of oxaliplatin-added chemotherapy and capecitabine monotherapy in high-risk stage II/stage III elderly colon cancer patients.

METHODS

Colon cancer patients ≥70 years of age who received adjuvant chemotherapy at Inje University Busan Paik Hospital between February 2009 to April 2016 were included. Patients were separated into the oxaliplatin-added group and capecitabine monotherapy group. The primary outcomes were CSS and OS.

RESULTS

Of 74 patients, 45 received oxaliplatin-added chemotherapy and 29 received capecitabine monotherapy. There was no difference between the two groups in CSS or OS (p = 0.9670 and p = 0.6801, respectively). The N stage was significantly associated with CSS in both uni/multivariate analysis (p = 0.0565 and p = 0.0347, respectively). The oxaliplatin-added group had more stage III patients, so we performed a subgroup analysis of CSS and OS based on stage, which also showed no significant difference.

CONCLUSIONS

Capecitabine monotherapy is an oncologically safe regimen compared to oxaliplatin-added regimens in elderly patients with high-risk stage II/stage III colon cancer.

SICCR Current status of Crohn’s disease surgery collaborative, Celentano V, Pellino G, Rottoli M, Poggioli G, Sica G, Giglio MC, Campanelli M, Coco C, Rizzo G, Sionne F, Colombo F, Sampietro G, Lamperti G, Foschi D, Ficari F, Vacca L, Cricchio M, Giudici F, Selvaggi L, Sciaudone G, Peltrini R, Manfreda A, Bucci L, Galleano R, Ghazouani O, Zorcolo L, Deidda S, Restivo A, Braini A, Di Candido F, Sacchi M, Carvello M, Martorana S, Bordignon G, Angriman I, Variola A, Barugola G, Di Ruscio M, Tanzanu M, Geccherle A, Tropeano FP, Luglio G, Sasia D, Migliore M, Giuffrida MC, Marrano E, Moretto G, Impellizzeri H, Gallo G, Vescio G, Sammarco G, Terrosu G, Calini G, Bondurri A, Maffioli A, Zaffaroni G, Resegotti A, Mistrangelo M, Allaix ME, Botti F, Prati M, Boni L, Perotti S, Mineccia M, Giuliani A, Romano L, Graziano GMP, Pugliese L, Pietrabissa A, Delaini GG, Spinelli A, Selvaggi F. Surgical treatment of colonic Crohn's disease: a national snapshot study

AIM

The different surgical options for patients with colonic Crohn's disease (CD) include segmental colectomy, subtotal colectomy or proctocolectomy with end ileostomy. We present a national, multicentre study, promoted by the Italian Society of Colorectal Surgery with the aim to collect benchmark data and national variations on multidisciplinary management and postoperative outcomes of patients undergoing surgery for colonic CD.

METHODS

All adult patients having elective surgery for colonic CD from June 2018 to May 2019 were eligible for participation in this retrospective study. The primary outcome measure was postoperative morbidity within 30 days of surgery.

RESULTS

One hundred twenty-two patients were included: 55 subtotal colectomy, 30 segmental colectomy, 25 proctectomy and 12 proctocolectomy. Eighty-six patients (70.4%) were discussed at the inflammatory bowel disease (IBD) multidisciplinary team meeting (MDT) prior to surgery. This ranged from 76.6% for segmental colectomy to 60% for subtotal colectomy, 66.6% for proctocolectomy and 48% for proctectomy. The proportion of patients counselled by a stoma nurse preoperatively was 50%. Laparoscopy was associated with reduced postoperative morbidity (p = 0.017) and shorter length of hospital stay (p < 0.001), whilst pre-operative anti-TNF was associated with Dindo-Clavien ≥ 3 complications (p = 0.023) and longer in-hospital stay (p = 0.007). The main procedure performed (segmental colectomy, subtotal colectomy, proctocolectomy or proctectomy) was not associated with postoperative morbidity (p = 0.626).

CONCLUSIONS

Surgery for colonic CD has a high rate of postoperative complications. Almost a third of the patients were not preoperatively discussed at the IBD MDT, whilst the use of minimally invasive surgery for surgical treatment of colonic CD ranges from 40 to 66%.

WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting

BACKGROUND

Despite the current therapeutic options for the treatment of inflammatory bowel disease, surgery is still frequently required in the emergency setting, although the number of cases performed seems to have decreased in recent years. The World Society of Emergency Surgery decided to debate in a consensus conference of experts, the main pertinent issues around the management of inflammatory bowel disease in the emergent situation, with the need to provide focused guidelines for acute care and emergency surgeons.

METHOD

A group of experienced surgeons and gastroenterologists were nominated to develop the topics assigned and answer the questions addressed by the Steering Committee of the project. Each expert followed a precise analysis and grading of the studies selected for review. Statements and recommendations were discussed and voted at the Consensus Conference of the 6th World Society of Emergency Surgery held in Nijmegen (The Netherlands) in June 2019.

CONCLUSIONS

Complicated inflammatory bowel disease requires a multidisciplinary approach because of the complexity of this patient group and disease spectrum in the emergency setting, with the aim of obtaining safe surgery with good functional outcomes and a decreasing stoma rate where appropriate.

Colectomy rates for ulcerative colitis in England 2003-2016

BACKGROUND

Temporal trends in colectomy rate for ulcerative colitis (UC) are particularly relevant in the current era of published IBD standards and changing approach to salvage of acute severe disease.

AIMS

To investigate temporal trends in colectomy for UC using English population data.

METHODS

The Hospital Episode Statistics (HES) were interrogated between 2003-2016 with two patient groups investigated independently. An 'emergency' cohort: emergency UC admission ≥ three days, age ≥18 and a 'total population' cohort: all English patients undergoing colectomy for UC. Mixed methods analyses were utilised.

RESULTS

Emergency cohort: 37 981 patients, 49% female, median age 46. The one- and three-year incidence of colectomy after acute admission was 0.17 and 0.21. Interrupted time series (ITS) analysis suggested reductions in colectomy rate of 4% per year after 2008 at 30 and 90 days following emergency admission, with no significant reduction ≥1 year. Mortality and laparoscopy rates improved when avoiding colectomy at index and emergency admissions; however, the proportion of emergency colectomies after salvage at index admission significantly increased during the study period. Total population cohort: 17 580 patients underwent colectomy for UC between 2003 and 2016, demonstrating a 3.1% annual reduction in total and elective colectomies after 2008, but no reduction in emergency colectomies.

CONCLUSION

Reductions in short-term colectomy rates after emergency admission for UC do not persist beyond one year. Emergency colectomy rates remain unchanged. Reduced rates are probably due to multi-modal improvements in IBD care. A lack of data regarding disease severity precludes further interpretation of appropriate medical salvage and timely surgery.

The role of Kono-S anastomosis and mesenteric resection in reducing recurrence after surgery for Crohn's disease: a systematic review

AIM

Recurrence after surgery for Crohn's disease is common. Anastomotic configuration may influence recurrence and the mesentery may be key. Recently the Kono-S anastomosis and radical mesenteric excision have been proposed as methods of reducing recurrence. We analysed the literature pertaining to these novel techniques.

METHOD

We searched MEDLINE, Embase and the Cochrane Library for, and selected, studies evaluating Kono-S anastomosis and/or radical mesenteric excision in Crohn's disease. We assessed methodological quality and risk of bias using the Cochrane risk of bias tool for randomized controlled trials and the Joanna Briggs Institute tool for nonrandomized trials. A narrative synthesis was used to summarize the findings.

RESULTS

Nine studies (896 patients) were identified. Apart from one randomized controlled trial with a low risk of bias the overall level of evidence was poor (Grade IV). The Kono-S anastomosis was associated with a lower incidence of endoscopic and surgical recurrence (0%-3.4% vs 15%-24.4% respectively). Complications, particularly anastomotic leak rate, were also lower (1.8% vs 9.3% respectively). Evidence from a single poor quality study suggested that mesenteric excision may reduce surgical recurrence rates compared with mesentery preservation.

CONCLUSION

The existing literature suggests that the Kono-S anastomosis is safe and may reduce endoscopic and surgical recurrence, but level of evidence is mainly poor. One element of the Kono-S technique, preservation of the mesentery, may be detrimental to recurrence. Further, higher quality, studies are required to investigate these techniques. Such studies should consider the impact of the degree of mesenteric resection in addition to the anastomosis on disease recurrence.

SICCR Current Status of Crohn’s Disease Surgery Collaborative. National variations in perioperative assessment and surgical management of Crohn's disease: a multicentre study

AIM

Crohn's disease (CD) requires a multidisciplinary approach and surgery should be undertaken by dedicated colorectal surgeons with audited outcomes. We present a national, multicentre study, with the aim to collect benchmark data on key performance indicators in CD surgery, to highlight areas where standards of CD surgery excel and to facilitate targeted quality improvement where indicated.

METHODS

All patients undergoing ileocaecal or redo ileocolic resection in the participating centres for primary and recurrent CD from June 2018 to May 2019 were included. The main objective was to collect national data on hospital volume and practice variations. Postoperative morbidity was the primary outcome. Laparoscopic surgery and stoma rate were the secondary outcomes.

RESULTS

In all, 715 patients were included: 457 primary CD and 258 recurrent CD with a postoperative morbidity of 21.6% and 34.7%, respectively. Laparoscopy was used in 83.8% of primary CD compared to 31% of recurrent CD. Twenty-five hospitals participated and the total number of patients per hospital ranged from 2 to 169. Hospitals performing more than 10 primary CD procedures per year showed a higher adoption of laparoscopy and bowel sparing surgery.

CONCLUSIONS

There is significant heterogeneity in the number of CD surgeries performed per year nationally in Italy. Our data suggest that high-volume hospitals perform more complex procedures, with a higher adoption of bowel sparing surgery. The rate of laparoscopy in high-volume hospitals is higher for primary CD but not for recurrent CD compared with low-volume hospitals.

Impact of Randomized Controlled Trials in the Social Media: Does Science Trend As Much As Everyday Events?

BACKGROUND

The approach to the scientific literature is evolving. Currently, dissemination of articles happens in real time through social media (SoMe) channels, and little is known about its impact in medicine. The aim of this study was to investigate if SoMe dissemination followed trends independent from articles type and content.

METHODS

First, the SoMe engagement of a popular theme (#BlackFriday) and a relevant theme (#ClimateChange) was compared using a SoMe analytic tool to test if the popular theme would reach more engagement. In a second analysis, themes in colorectal surgery in the SoMe community were explored. Altmetric Explorer was searched for the term "colorectal surgery" and the outputs were categorized into 'randomized controlled trials' (RCTs) and 'other studies'. Subgroups were compared for the Altmetric scores using statistical analyses.

RESULTS

The analytic tool documented that #BlackFriday outnumbered #ClimateChange in mentions and engagement (1.6 million vs 127.000 mentions). Following, Altmetric Explorer identified 1381 articles, including 92 RCTs (7.1%). Overall, 25,554 mentions were documented from 1205 outputs (97.0% by Twitter). A greater percentage of "other studies" ranked in the lower Altmetric score categories (p = 0.0007). Similarly, the median Altmetric score was higher in the RCT subgroup comparing with "other studies" (6.5 vs. 2.0, Mann-Whitney p = 0.0001).

CONCLUSIONS

In this study, RCTs represented just the 7.1% of the studies and produced 11% of Twitter outputs. The median Altmetric scores obtained by RCTs were higher than those of other studies.

Population-Based Analysis of Adherence to Postdischarge Extended Venous Thromboembolism Prophylaxis After Colorectal Resection

BACKGROUND

Prevention of venous thromboembolism after colorectal surgery remains challenging. National guidelines endorse thromboembolism prophylaxis for 4 weeks after colorectal cancer resection. Expert consensus favors extended prophylaxis after IBD surgery. The actual frequency of prescription after resection remains unknown.

OBJECTIVE

This study aimed to assess prescription of extended, postdischarge venous thromboembolism prophylaxis after resection in Michigan.

DESIGN

This is a retrospective review of elective colorectal resections within a statewide collaborative receiving postdischarge, extended-duration prophylaxis.

SETTING

This study was conducted between October 2015 and February 2018 at an academic center.

PATIENTS

A total of 5722 patients (2171 with colorectal cancer, 266 with IBD, and 3285 with other).

MAIN OUTCOME MEASURES

We compared the prescription of extended, postdischarge prophylaxis over time, between hospitals and by indication.

RESULTS

Of 5722 patients, 373 (6.5%) received extended-duration prophylaxis after discharge. Use was similar between patients undergoing surgery for cancer (282/2171, 13.0%) or IBD (31/266, 11.7%, p = 0.54), but was significantly more common for both patients undergoing surgery for cancer or IBD in comparison with patients with other indications (60/3285, 1.8%, p < 0.001). Use increased significantly among patients with cancer (6.8%-16.8%, p < 0.001) and patients with IBD (0%-15.1%, p < 0.05) over the study period. For patients with other diagnoses, use was rare and did not vary significantly (1.5%-2.3%, p = 0.49). Academic centers and large hospitals (>300 beds) were significantly more likely to prescribe extended-duration prophylaxis for all conditions (both p < 0.001), with the majority of prophylaxis concentrated at only a few hospitals.

LIMITATIONS

This study was limited by the lack of assessment of actual adherence, small number of observed venous thromboembolism events, small sample of patients with IBD, and restriction to the state of Michigan.

CONCLUSIONS

The use of extended-duration venous thromboembolism prophylaxis after discharge is increasing, but remains uncommon in most hospitals. Efforts to improve adherence may require quality implementation initiatives or targeted payment incentives. See Video Abstract at http://links.lww.com/DCR/B193. ANÁLISIS POBLACIONAL DE LA ADHERENCIA A LA PROFILAXIS ANTI-TROMBÓTICA EXTENDIDA (TEV) EN PACIENTES DE ALTA LUEGO DE UNA RESECCIÓN COLORECTAL.: La prevención del tromboembolismo venoso después de cirugía colorrectal sigue siendo un desafío. Las guías nacionales han aprobado la profilaxia del tromboembolismo durante cuatro semanas luego de una resección de cáncer colorrectal. El consenso de expertos favorece la profilaxia extendida solamente después de la cirugía por enfermedad inflamatoria intestinal. La frecuencia real de prescripción después de la resección colorrectal sigue siendo desconocida.Evaluar la prescripción de profilaxia prolongada de tromboembolismo venoso después del alta luego de una resección colorrectal en Michigan.Revisión retrospectiva de las resecciones colorrectales electivas seguidas de una profilaxia de larga duración con el apoyo de todo el estado (MI).Este estudio se realizó entre octubre de 2015 y febrero de 2018 en un solo centro académico.Un universo de 5722 pacientes operados (2171 por cáncer colorrectal, 266 por enfermedad inflamatoria intestinal, 3285 por otros diagnósticos).Se comparó la prescripción de profilaxia prolongada después del alta según la duración, los hospitales y la indicación.De 5722 pacientes, 373 (6.5%) recibieron profilaxia de duración prolongada después del alta. El uso fue similar entre pacientes sometidos a cirugía por cáncer (282/2171, 13.0%) o enfermedad inflamatoria intestinal (31/266, 11.7%, p = 0.54), pero fue significativamente más común para ambos en comparación con pacientes con otras indicaciones (60/3285, 1.8%, p < 0.001). El uso aumentó significativamente entre pacientes con cáncer (6.8% a 16.8% (p < 0.001)) y en pacientes con enfermedad inflamatoria intestinal (0% a 15.1%, p < 0.05) durante el período de estudio. Para pacientes con otros diagnósticos, su utilización fue rara y no varió significativamente (1.5% a 2.3%, p = 0.49). Los centros académicos y los grandes hospitales (>300 camas) tenían mayor probabilidad de prescribir la profilaxia de duración extendida en todas las afecciones (ambas p < 0.001), pero la mayoría de las profilaxis se concentraron el algunos pocos grandes hospitales.Este estudio estuvo limitado por la falta de evaluación de actuales adherentes, por el pequeño número de eventos tromboembólicos venosos observados, por la pequeña muestra de pacientes con enfermedad inflamatoria intestinal y debido a ciertas restricciones en el estado de Michigan.El uso de profilaxia para el tromboembolismo venoso de duración prolongada después del alta está en aumento, pero su uso sigue siendo poco frecuente en la mayoría de los hospitales. Los esfuerzos para mejorar la adherencia al tratamiento pueden requerir iniciativas de mejoría en la calidad o incentivos específicos de reembolso. Consulte Video Resumen en http://links.lww.com/DCR/B193. (Traducción-Dr. Xavier Delgadillo).

Rectal stump management in inflammatory bowel disease: a cohort study, systematic review and proportional analysis of perioperative complications

BACKGROUND

The aim of this study was to analyse local single-institution data and perform a systematic review of the literature to calculate precise risk estimates of rectal stump-related morbidity and mortality following subtotal colectomy in patients with inflammatory bowel disease (IBD), including Crohn's colitis, ulcerative colitis and indeterminate colitis.

METHODS

Institutional information systems were interrogated to obtain local patient data. A systematic review of MEDLINE and EMBASE was performed to identify relevant articles. Fixed-effects or random-effects meta-analysis of proportions was performed to calculate pooled incidence estimates, including local data.

RESULTS

Sixty-one patients were included locally and all had their rectal stump closed intra-abdominally. Four patients (8.3%) had a rectal stump perforation and 30-day mortality was 0. Fourteen papers were included in our review alongside local data, with a total of 1330 patients included. Pooled mortality was 1.7% (95% confidence interval, CI 1.0-2.8), pooled incidence of pelvic abscess/sepsis, stump leak and wound infection was 5.7% (95% CI 4.4-7.3), 4.9% (95% CI 3.7-6.6) and 11.3% (95% CI 7.8-16), respectively. Subcutaneous placement of the stump was associated with the highest incidence of stump leak (12.6%, 95% CI 8.3-18.6), and closure of the stump with both staples and suture was associated with the highest incidence of pelvic abscess (11.1%, 95% CI 5.8-20.3). Mortality and the incidence of wound infection were similar across stump closure techniques. There was evidence suggesting considerable heterogeneity and publication bias among studies.

CONCLUSIONS

This study provides estimates of morbidity associated with the rectal stump after subtotal colectomy for IBD. A closed intra-abdominal stump seems to be associated with the highest rate of pelvic abscess/sepsis. Further work in form of an international collaborative project would allow individual patient data analysis and identification of risk factors for complications.

Preoperative assessment of skeletal muscle mass during magnetic resonance enterography in patients with Crohn's disease

Measurement of the psoas muscle area has been applied to estimate lean muscle mass as a surrogate marker of sarcopenia, but there is a paucity of evidence regarding the influence of sarcopenia on clinical outcomes following inflammatory bowel disease surgery. The aim of this study was to evaluate the association between MRI enterography defined sarcopenia and postoperative complications in patients undergoing elective ileocaecal resection for Crohn’s disease. To obtain cross sectional area measurement of the psoas muscle, the freehand area tool was used to trace the margin of each psoas muscle at the level of L4, with the sum recorded as Total Psoas Area (TPA). The total cross sectional muscle area of the abdominal wall was recorded as Skeletal Muscle Area (SMA), while myosteatosis was measured by normalising the psoas muscle intensity with the mean intensity of the cerebrospinal fluid. The primary outcome was the incidence of 30-day postoperative complications in patients in the lowest quartile of TPA and SMA. 31 patients were included and ten patients (32.25%) developed postoperative complications within 30 days of surgery. The cut-off values for the lowest quartile for TPA were 11.93 cm² in men and 9.77 cm² in women, including a total of 8 patients (25.8%) with 5 patients in this group (62.5%) developing postoperative complications and 3 patients (37.5%) Clavien-Dindo class ≥ 3 complications. The cut-off values for the lowest quartile for SMA were 73.49 cm² in men and 65.85 cm² in women, with 4 patients out of 8 (50%) developing postoperative complications. Psoas muscle cross sectional area and skeletal mass area can be estimated on Magnetic Resonance Enterography as surrogate markers of sarcopenia with high inter-observer agreement.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of ulcerative colitis management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of ulcerative colitis. The committee was able to identify some points of major disagreement and suggested strategies to improve the quality of available data and acceptance of guidelines.

The Portsmouth protocol for intra-operative ultrasound of the small bowel in Crohn's disease

AIM

Bowel preservation is paramount in Crohn's disease surgery as affected patients are typically young adults at risk of having several abdominal surgical procedures during their lifetime. Intra-operative assessment of the extent and location of Crohn's disease is not standardized and is left to a mixture of the surgeon's experience, tactile feedback, macroscopic appearance and preoperative imaging. The aim of this study was to describe the technical steps of a standardized protocol for intra-operative ultrasound assessment of the small bowel in patients undergoing surgery for ileocolic Crohn's disease.

METHOD

After laparoscopic mobilization of the bowel, a periumbilical incision is performed for extracorporeal division of the mesentery and the resection and anastomosis. A gastrointestinal consultant radiologist, with expertise in Crohn's disease imaging and abdominal ultrasound, performs full intra-operative assessment of the small bowel by applying a sterile ultrasound probe directly to the bowel, prior to resection being performed by the surgeon. The bowel is assessed through the wound protector with a sterile technique and the length, location and number of segments is documented together with further quantitative assessment using the METRIC (MR enterography or ultrasound in Crohn's disease) scoring guide.

RESULTS

A step-by-step protocol for intra-operative ultrasound evaluation of the entire small bowel is described.

CONCLUSIONS

A standardized approach to intra-operative evaluation of the extent and location of Crohn's disease is desirable. Intra-operative ultrasound may provide added value for assessment of proximal and multifocal Crohn's disease.

Inflammatory bowel disease (IBD) position statement of the Italian Society of Colorectal Surgery (SICCR): general principles of IBD management

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of inflammatory bowel disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the general principles of surgical treatment of inflammatory bowel disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.