Role of mesenteric component in Crohn’s disease: A friend or foe?

Quantitative assessment of transmural remission in Crohn's disease using low dose computed tomography (CT) enterography perfusion imaging: a single-centre study based on intestinal microcirculation

AIM

To assess transmural remission in patients with Crohn's disease using low-dose small bowel computed tomography (CT) perfusion scans.

MATERIALS AND METHODS

Forty six patients were divided into active and remission phases based on Crohn's Disease Activity Index (CDAI) and C-reactive protein (CRP). Dual-source CT enterography with low-dose perfusion scans was conducted to generate perfusion parameter maps, including blood flow (BF), blood volume (BV), time to peak (TTP), mean transit time (MTT), and permeability of surface (PS). We compared differences in perfusion parameter values of intestinal walls, mesenteric fat, and lymph nodes between two groups. Receiver operating characteristic (ROC) curves were plotted, and area under the curve (AUC), sensitivity, specificity, and cutoff values were calculated.

RESULTS

The BF, BV, TTP, MTT, and PS values of the intestinal wall were significantly higher in the active phase (P0.05). Additionally, lymph node BF and TTP displayed significant differences (P<0.01).

CONCLUSION

Dual-source CT enterography with low-dose perfusion scans enables quantitative assessment of Crohn's disease microcirculation in intestinal walls, mesenteric fat, and lymph nodes. These quantitative indicators provide strong diagnostic efficacy and offer insights into whether the disease is in transmural remission.

Exploring gut microbiota as a novel therapeutic target in Crohn's disease: Insights and emerging strategies

Extensive research has investigated the etiology of Crohn's disease (CD), encompassing genetic predisposition, lifestyle factors, and environmental triggers. Recently, the gut microbiome, recognized as the human body's second-largest gene pool, has garnered significant attention for its crucial role in the pathogenesis of CD. This paper investigates the mechanisms underlying CD, focusing on the role of 'creeping fat' in disease progression and exploring emerging therapeutic strategies, including fecal microbiota transplantation, enteral nutrition, and therapeutic diets. Creeping fat has been identified as a unique pathological feature of CD and has recently been found to be associated with dysbiosis of the gut microbiome. We characterize this dysbiotic state by identifying key microbiome-bacteria, fungi, viruses, and archaea, and their contributions to CD pathogenesis. Additionally, this paper reviews contemporary therapies, emphasizing the potential of biological therapies like fecal microbiota transplantation and dietary interventions. By elucidating the complex interactions between host-microbiome dynamics and CD pathology, this article aims to advance our understanding of the disease and guide the development of more effective therapeutic strategies for managing CD.

The Role of Adipocytes Recruited as Part of Tumor Microenvironment in Promoting Colorectal Cancer Metastases

Adipose tissue dysfunction, which is associated with an increased risk of colorectal cancer (CRC), is a significant factor in the pathophysiology of obesity. Obesity-related inflammation and extracellular matrix (ECM) remodeling promote colorectal cancer metastasis (CRCM) by shaping the tumor microenvironment (TME). When CRC occurs, the metabolic symbiosis of tumor cells recruits adjacent adipocytes into the TME to supply energy. Meanwhile, abundant immune cells, from adipose tissue and blood, are recruited into the TME, which is stimulated by pro-inflammatory factors and triggers a chronic local pro-inflammatory TME. Dysregulated ECM proteins and cell surface adhesion molecules enhance ECM remodeling and further increase contractibility between tumor and stromal cells, which promotes epithelial-mesenchymal transition (EMT). EMT increases tumor migration and invasion into surrounding tissues or vessels and accelerates CRCM. Colorectal symbiotic microbiota also plays an important role in the promotion of CRCM. In this review, we provide adipose tissue and its contributions to CRC, with a special emphasis on the role of adipocytes, macrophages, neutrophils, T cells, ECM, and symbiotic gut microbiota in the progression of CRC and their contributions to the CRC microenvironment. We highlight the interactions between adipocytes and tumor cells, and potential therapeutic approaches to target these interactions.

Long-term Outcomes of the Kono-S Anastomosis: A Multicenter Study

BACKGROUND

Postoperative recurrence remains a significant problem in Crohn's disease, and the mesentery is implicated in the pathophysiology. The Kono-S anastomosis was designed to exclude the mesentery from a wide anastomotic lumen, limit luminal distortion and fecal stasis, and preserve innervation and vascularization.

OBJECTIVE

To review postoperative complications and long-term outcomes of the Kono-S anastomosis in a large series of consecutive unselected patients with Crohn's disease.

DESIGN

Retrospective study of prospectively collected patients.

SETTINGS

Four tertiary referral centers.

PATIENTS

Consecutive patients with Crohn's disease who underwent resection with Kono-S anastomosis between May 2010 and June 2022.

INTERVENTIONS

Extracorporeal handsewn Kono-S anastomosis.

MAIN OUTCOME MEASURES

Postoperative outcomes and recurrence defined as endoscopic, clinical, laboratory, or surgical, including endoscopic, intervention.

RESULTS

A total of 262 consecutive patients (53.4% male) were included. The mean duration of disease at surgery was 145.1 months. One hundred thirty-five patients (51.5%) had previous abdominal surgery for Crohn's disease. Forty-four patients (17%) were actively smoking and 150 (57.3%) were on biologic therapy. Anastomotic failure occurred in 4 (1.5%), with 2 patients requiring reoperation (0.7%). Sixteen patients had postoperative surgical site infection (6.1%). With a median follow-up of 49.4 months, 20 patients (7.6%) were found to have surgical recurrence. In the multivariate analysis, perianal disease (OR = 2.83, p = 0.001), urgent/emergent surgery (OR = 3.23, p = 0.007), and postoperative use of steroids (OR = 2.29, p = 0.025) were associated with increased risk of overall recurrence.

LIMITATIONS

Retrospective study and variability of perioperative medical therapy.

CONCLUSIONS

This study showed very low postoperative complication rates despite the complexity of the patient population. There was a low rate of surgical recurrence, likely due to the intrinsic advantages of the anastomotic configuration and the low rate of postoperative septic complications. In experienced hands, the Kono-S anastomosis is a safe technique with very promising short- and long-term results. Randomized controlled trials are underway to validate this study's findings. See Video Abstract .

RESULTADO A LARGO PLAZO DE LA ANASTOMOSIS KONOS UN ESTUDIO MULTICNTRICO

ANTECEDENTES:La recurrencia posoperatoria sigue siendo un problema importante en la enfermedad de Crohn y el mesenterio está implicado en la fisiopatología. La anastomosis Kono-S fue diseñada para excluir el mesenterio de una anastomosis amplia, limitar la distorsión luminal y la estasis fecal y preservar la inervación y vascularización.OBJETIVO:Revisar las complicaciones posoperatorias y los resultados a largo plazo de la anastomosis Kono-S en una gran serie de pacientes consecutivos no seleccionados con enfermedad de Crohn.DISEÑO:Estudio retrospectivo de pacientes recolectados prospectivamente.ESCENARIO:Cuatro centros de referencia terciarios.PACIENTES:Pacientes consecutivos con enfermedad de Crohn sometidos a resección con anastomosis Kono-S entre mayo de 2010 y junio de 2022.INTERVENCIONES:Anastomosis Kono-S extracorpórea manual.PRINCIPALES MEDIDAS DE RESULTADO:Resultados posoperatorios y recurrencia definidos como endoscópicos, clínicos, de laboratorio o quirúrgicos, incluida la intervención endoscópica.RESULTADOS:Se incluyeron un total de 262 pacientes consecutivos (53,4% varones). La duración media de la enfermedad al momento de la cirugía fue de 145,1 meses. Ciento treinta y cinco pacientes (51,5%) habían tenido cirugía abdominal previa por enfermedad de Crohn. Cuarenta y cuatro pacientes (17%) eran fumadores activos y 150 (57,3%) estaban en tratamiento biológico. Se produjo filtración anastomótica en 4 (1,5%) y 2 pacientes requirieron reoperación (0,7%). Dieciséis pacientes tuvieron infección postoperatoria del sitio quirúrgico (6,1%). Con una mediana de seguimiento de 49,4 meses, se encontró que 20 pacientes (7,6%) tuvieron recurrencia quirúrgica. En el análisis multivariado, la enfermedad perianal (OR = 2,83, p = 0,001), la cirugía urgente/emergente (OR = 3,23, p = 0,007), el uso postoperatorio de esteroides (OR = 2,29, p = 0,025) se asociaron con un mayor riesgo de recurrencia general.LIMITACIÓN:Estudio retrospectivo. Variabilidad del tratamiento médico perioperatorio.CONCLUSIONES:Nuestro estudio mostró tasas de complicaciones postoperatorias muy bajas a pesar de la complejidad de la población de pacientes. Hubo una baja tasa de recurrencia quirúrgica, probablemente debido a las ventajas intrínsecas de la configuración anastomótica y la baja tasa de complicaciones sépticas posoperatorias. En manos experimentadas, la anastomosis Kono-S es una técnica segura con resultados muy prometedores a corto y largo plazo. Se están realizando estudios randomizados controlados para validar nuestros hallazgos. (Traducción-Dr. Felipe Bellolio ).

Differentiating gastrointestinal tuberculosis and Crohn's disease- a comprehensive review

Gastrointestinal Tuberculosis (GITB) and Crohn's disease (CD) are both chronic granulomatous diseases with a predilection to involve primarily the terminal ileum. GITB is often considered a disease of the developing world, while CD and inflammatory bowel disease are considered a disease of the developed world. But in recent times, the epidemiology of both diseases has changed. Differentiating GITB from CD is of immense clinical importance as the management of both diseases differs. While GITB needs anti-tubercular therapy (ATT), CD needs immunosuppressive therapy. Misdiagnosis or a delay in diagnosis can lead to catastrophic consequences. Most of the clinical features, endoscopic findings, and imaging features are not pathognomonic for either of these two conditions. The definitive diagnosis of GITB can be clinched only in a fraction of cases with microbiological positivity (acid-fast bacilli, mycobacterial culture, or PCR-based tests). In most cases, the diagnosis is often based on consistent clinical, endoscopic, imaging, and histological findings. Similarly, no single finding can conclusively diagnose CD. Multiparametric-based predictive models incorporating clinical, endoscopy findings, histology, radiology, and serology have been used to differentiate GITB from CD with varied results. However, it is limited by the lack of validation studies for most such models. Many patients, especially in TB endemic regions, are initiated on a trial of ATT to see for an objective response to therapy. Early mucosal response assessed at two months is an objective marker of response to ATT. Prolonged ATT in CD is recognized to have a fibrotic effect. Therefore, early discrimination may be vital in preventing the delay in the diagnosis of CD and avoiding a complicated course.