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Kappenberger AS, Schardey J, Wirth U, Kühn F, Werner J, Zimmermann P. Clinical outcomes and perioperative morbidity and mortality following segmental resections of the colon for Crohn's colitis. Int J Colorectal Dis 2024; 39:36. [PMID: 38456914 PMCID: PMC10923963 DOI: 10.1007/s00384-024-04596-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/09/2024]
Abstract
INTRODUCTION Crohn's disease (CD) is a chronic inflammatory bowel disease of a multifactorial pathogenesis. Recently numerous genetic variants linked to an aggressive phenotype were identified, leading to a progress in therapeutic options, resulting in a decreased necessity for surgery. Nevertheless, surgery is often inevitable. The aim of the study was to evaluate possible risk factors for postoperative complications and disease recurrence specifically after colonic resections for CD. PATIENTS AND METHODS A total of 241 patients who underwent colonic and ileocaecal resections for CD at our instiution between 2008 and 2018 were included. All data was extracted from clinical charts. RESULTS Major complications occurred in 23.8% of all patients. Patients after colonic resections showed a significantly higher rate of major postoperative complications compared to patients after ICR (p = < 0.0001). The most common complications after colonic resections were postoperative bleeding (22.2%), the need for revision surgery (27.4%) and ICU (17.2%) or hospital readmission (15%). As risk factors for the latter, we identified time interval between admission and surgery (p = 0.015) and the duration of the surgery (p = 0.001). Isolated distal resections had a higher risk for revision surgery and a secondary stoma (p = 0.019). Within the total study population, previous bowel resections (p = 0.037) were identified as independent risk factors for major perioperative complications. CONCLUSION The results indicate that both a complex surgical site and a complex surgical procedure lead to a higher perioperative morbidity in colonic resections for Crohn's colitis.
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Affiliation(s)
- Alina-Sophie Kappenberger
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany
| | - Josefine Schardey
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany
| | - Ulrich Wirth
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany
| | - Florian Kühn
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany
| | - Petra Zimmermann
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany.
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Obi M, DeRoss AL, Lipman J. Use of the Kono-S anastomosis in pediatric Crohn's disease: a single-institution experience. Pediatr Surg Int 2023; 39:290. [PMID: 37947950 DOI: 10.1007/s00383-023-05572-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVES About 24% of children with Crohn's Disease (CD) require surgery. In 2003, Kono et al. described a novel anastomosis reported to decrease the rate of anastomotic CD recurrence. Subsequent studies have reproduced these outcomes, but none has demonstrated its effect in pediatric patients. This study evaluates short-term outcomes of pediatric patients following ileocolic resection and Kono-S anastomosis. METHODS A retrospective review of patients < 18 years old who underwent ileocolic resection followed by Kono-S anastomosis compared with those who underwent a stapled anastomosis. RESULTS Nine Kono-S patients were matched with nine patients preceding them who received traditional side-to-side and end-to-side anastomoses. All patients underwent minimally invasive surgery. Demographics, pre-operative medication usage, and symptom profiles were not significantly different. Traditional anastomosis (TA) patients had longer lengths of stay (4.6 vs 2.9 days; p = 0.03) but had no statistically significant differences in blood loss, procedure length, and pathologic findings. One Kono-S patient had a superficial surgical site infection, and one TA patient had an anastomotic leak requiring reoperation within 30 days. More TA patients experienced post-operative symptoms at both 30-day and 6-month follow-up (66.7% vs 33.3%; p = 0.16 and 77.8% vs 25%; p = 0.03). CONCLUSION The Kono-S anastomosis appears to be safe in pediatric CD when compared to traditional stapled anastomoses.
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Affiliation(s)
- Megan Obi
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
| | - Anthony L DeRoss
- Department of Pediatric Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jeremy Lipman
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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Calini G, Abdalla S, Abd El Aziz MA, Merchea A, Larson DW, Behm KT. Ileocolic resection for Crohn's disease: robotic intracorporeal compared to laparoscopic extracorporeal anastomosis. J Robot Surg 2023; 17:2157-2166. [PMID: 37264221 DOI: 10.1007/s11701-023-01635-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
Laparoscopy is the first-line approach in ileocolic resection for Crohn's disease. Emerging data has shown better short-term outcomes with robotic right colectomy for cancer when compared to laparoscopic approach. However, robotic ileocolic resection for Crohn's disease has only shown faster return to bowel function. We aimed to evaluate short-term outcomes of ileocolic resection for Crohn's disease between robotic intracorporeal anastomosis (RICA) and laparoscopic extracorporeal anastomosis (LECA). Patients undergoing minimally invasive ileocolic resections for Crohn's disease were retrospectively identified using a prospectively maintained database between 2014 and 2021 in two referral centers. Among the 239 patients, 70 (29%) underwent RICA while 169 (71%) LECA. Both groups were similar according to baseline and preoperative characteristics. RICA was associated with more intraoperative adhesiolysis and longer operative time [RICA: 238 ± 79 min vs. LECA: 143 ± 52 min; p < 0.001]. 30-day postoperative complications were not different between the two groups [RICA: 17/70(24%) vs. LECA: 54/169(32%); p = 0.238]. Surgical site infections [RICA: 0/70 vs. LECA: 16/169(10%); p = 0.004], intra-abdominal septic complications [RICA: 0/70 vs. LECA: 14/169(8%); p = 0.012], and Clavien-Dindo ≥ III complications [RICA: 1/70(1%) vs. LECA: 15/169(9%); p = 0.044] were less frequent in RICA. Return to bowel function [RICA: 2.1 ± 1.1 vs. LECA: 2.6 ± 1.2 days; p = 0.002] and length of stay [RICA: 3.4 ± 2.2 vs. LECA: 4.2 ± 2.5 days; p = 0.015] were shorter after RICA, with similar readmission rates. RICA demonstrated better short-term postoperative outcomes than LECA, with reduced Clavien-Dindo ≥ III complications, surgical site infections, intra-abdominal septic complications, shorter length of stay, and faster return to bowel function, despite the longer operative time.
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Affiliation(s)
- Giacomo Calini
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Amit Merchea
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Bislenghi G, Vancoillie PJ, Fieuws S, Verstockt B, Sabino J, Wolthuis A, D'Hoore A. Effect of anastomotic configuration on Crohn's disease recurrence after primary ileocolic resection: a comparative monocentric study of end-to-end versus side-to-side anastomosis. Updates Surg 2023; 75:1607-1615. [PMID: 37308742 DOI: 10.1007/s13304-023-01561-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/03/2023] [Indexed: 06/14/2023]
Abstract
There is ongoing debate whether the type of anastomosis following intestinal resection for Crohn's disease (CD) can impact on complications and postoperative recurrence. The aim of the present study is to describe the outcomes of side-to-side (S-S) vs end-to-end (E-E) anastomosis after ileocecal resection for CD. A retrospective comparative study was conducted in consecutive CD patients who underwent primary ileocecal resection between 2005 and 2013. All patients underwent colonoscopy 6 months postoperatively to assess endoscopic recurrence, defined as Rutgeerts' score (RS) ≥ i2. Surgical recurrence implied reoperation due to CD activity at the anastomotic site. Modified surgical recurrence was defined as the need for reoperation or balloon-dilation. Perioperative factors related to recurrence were evaluated. Of the 127 patients included, 51 (40.2%) received an E-E anastomosis. Median follow-up was longer in the E-E group (8.62 vs 13.68 years). Apart from the microscopic resection margins, patient, disease and surgical characteristics were similar between both groups. Anastomotic complications were comparable (S-S 5.3% vs E-E 5.8%, p = 1.00)0. Postoperatively, biologicals were used in 55.3% and 62.7% (p = 0.47) in S-S and E-E patients, respectively. Endoscopic recurrence did not differ between S-S and E-E patients (78.9 vs 72.9%, p = 0.37), with no significant difference in RS values between both groups (p = 0.87). Throughout follow-up, a higher surgical (p = 0.04) and modified surgical recurrence (p = 0.002) rate was observed in the E-E anastomosis group. Type of anastomosis was an independent risk factor for modified surgical recurrence. The type of anastomosis did not influence endoscopic recurrence and immediate postoperative disease complications. However, the wide diameter and the morphologic characteristic of the stapled S-S anastomosis resulted in a significant reduced risk for surgical and endoscopic reintervention on the long term.
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Affiliation(s)
- Gabriele Bislenghi
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium.
| | - Peter-Jan Vancoillie
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Steffen Fieuws
- Interuniversity Center for Biostatistics and Statistical Bioinformatics, University of Leuven and Univerisity of Hasselt, Leuven, Hasselt, Belgium
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Joao Sabino
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Albert Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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Calini G, Abdalla S, Aziz MAAE, Behm KT, Shawki SF, Mathis KL, Larson DW. Incisional hernia rates between intracorporeal and extracorporeal anastomosis in minimally invasive ileocolic resection for Crohn's disease. Langenbecks Arch Surg 2023; 408:251. [PMID: 37382678 DOI: 10.1007/s00423-023-02976-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/10/2023] [Indexed: 06/30/2023]
Abstract
PURPOSE One-third of patients with Crohn's disease (CD) require multiple surgeries during their lifetime. So, reducing the incisional hernia rate is crucial. We aimed to define incisional hernia rates after minimally invasive ileocolic resection for CD, comparing intracorporeal anastomosis with Pfannenstiel incision (ICA-P) versus extracorporeal anastomosis with midline vertical incision (ECA-M). METHODS This retrospective cohort compares ICA-P versus ECA-M from a prospectively maintained database of consecutive minimally invasive ileocolic resections for CD performed between 2014 and 2021 in a referral center. RESULTS Of the 249 patients included: 59 were in the ICA-P group, 190 in the ECA-M group. Both groups were similar according to baseline and preoperative characteristics. Overall, 22 (8.8%) patients developed an imaging-proven incisional hernia: seven at the port-site and 15 at the extraction-site. All 15 extraction-site incisional hernias were midline vertical incisions [7.9%; p = 0.025], and 8 patients (53%) required surgical repair. Time-to-event analysis showed a 20% rate of extraction-site incisional hernia in the ECA-M group after 48 months (p = 0.037). The length of stay was lower in the intracorporeal anastomosis with Pfannenstiel incision group [ICA-P: 3.3 ± 2.5 vs. ECA-M: 4.1 ± 2.4 days; p = 0.02] with similar 30-day postoperative complication [11(18.6) vs. 59(31.1); p = 0.064] and readmission rates [7(11.9) vs. 18(9.5); p = 0.59]. CONCLUSION Patients in the ICA-P group did not encounter any incisional hernias while having shorter hospital length of stay and similar 30-day postoperative complications or readmission compared to ECA-M. Therefore, more consideration should be given to performing intracorporeal anastomosis with Pfannenstiel incision during Ileocolic resection in patients with CD to reduce hernia risk.
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Affiliation(s)
- Giacomo Calini
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Sherief F Shawki
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.
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Dane B, Remzi FH, Grieco M, Ginocchio L, Erkan A, Esen E, Dogru V, Huang C. Preoperative cross-sectional imaging findings in patients with surgically complex ileocolic Crohn's disease. Abdom Radiol (NY) 2023; 48:486-493. [PMID: 36329208 DOI: 10.1007/s00261-022-03716-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE The aim of this study was to evaluate the diagnostic performance of preoperative cross-sectional imaging findings using the SAR-AGA definitions in Crohn's disease (CD) patients who underwent ileocolic resection (ICR) with and without surgically complex ileocolic CD (CIC-CD). METHODS 69 CD patients [38 men; mean (± SD) age: 40.6 (16.2) years] who underwent ICR were retrospectively classified by surgical complexity by a colorectal surgeon using operative findings. CIC-CD was defined as ileal CD, not confined to the distal ileum. Two radiologists retrospectively evaluated the preoperative imaging for the presence and type of penetrating disease, stricture, or probable stricture using the SAR-AGA consensus definitions. The diagnostic performance of preoperative imaging findings was compared for patients with and without CIC-CD. Estimated blood loss (EBL), operative time (OT), conversion to open surgery, diversion, and length of hospital stay (LOS) were compared. RESULTS 60.9% had CIC-CD and 79.7% underwent primary ICR. Penetrating disease was more common in patients with than without CIC-CD (76.2% vs. 40.7%, p = 0.0048) and similar among primary versus redo ICR (p = 0.12). Patients with CIC-CD had more complex fistulas (59.5% vs. 11.1%; p < 0.0001) and fewer simple fistulas (2.4% vs. 18.5%; p = 0.03) than those without. Mesenteric findings (abscess, inflammatory mass) were more frequent in patients with (35.7%) than without (0%) (p = 0.0002) CIC-CD. Stricture and probable stricture were similar (p = 0.59). CIC-CD patients had greater EBL (178 cc vs. 57 cc, p = 0.006), conversion rates (30% vs. 0%, p = 0.0026), and diversion (80% vs. 52%, p = 0.04). CONCLUSION Complex fistula, mesenteric abscess, or inflammatory mass defined by the SAR-AGA guidelines suggests CIC-CD. ICR for CIC-CD had greater EBL, conversion to open surgery, and diversion.
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Affiliation(s)
- Bari Dane
- NYU Langone Health Department of Radiology, 660 1st Avenue, New York, NY, 10016, USA.
| | - Feza H Remzi
- NYU Langone Health Department of Surgery, 550 1st Avenue, New York, NY, 10016, USA
| | - Michael Grieco
- NYU Langone Health Department of Surgery, 550 1st Avenue, New York, NY, 10016, USA
| | - Luke Ginocchio
- NYU Langone Health Department of Radiology, 660 1st Avenue, New York, NY, 10016, USA
| | - Arman Erkan
- NYU Langone Health Department of Surgery, 550 1st Avenue, New York, NY, 10016, USA
| | - Eren Esen
- NYU Langone Health Department of Surgery, 550 1st Avenue, New York, NY, 10016, USA
| | - Volkan Dogru
- NYU Langone Health Department of Surgery, 550 1st Avenue, New York, NY, 10016, USA
| | - Chenchan Huang
- NYU Langone Health Department of Radiology, 660 1st Avenue, New York, NY, 10016, USA
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Ferrandis C, Souche R, Bardol T. Reply to "A Commentary on "Personalized pre-habilitation reduces anastomotic complications compared to up front surgery before ileocolic resection in high-risk patients with Crohn's disease: A single center retrospective study" [Int. J. Surg. 105 (2022) 106815]". Int J Surg 2022; 108:106979. [PMID: 36396120 DOI: 10.1016/j.ijsu.2022.106979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/02/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Charlotte Ferrandis
- Department of Digestive Surgery (IBD Surgical Unit), University Hospital Center, Montpellier-Nimes University, 641 Avenue du Doyen Gaston Giraud, 34090, Montpellier, France
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Yang ML, Brar MS, Boughn A, Saini J, Kennedy E, MacRae H, de Buck Van Overstraten A. Does Oversewing Stapled Ileocolic Anastomoses for Crohn's Disease Reduce Anastomotic Complications? An Inverse-Probability Weighting Analysis of a Single Centre Cohort. J Gastrointest Surg 2022; 26:1951-1953. [PMID: 35178650 DOI: 10.1007/s11605-022-05247-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 12/07/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Mei Lucy Yang
- Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue Room 455, Toronto, ON, M5G1X5, Canada
| | - Mantaj S Brar
- Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue Room 455, Toronto, ON, M5G1X5, Canada
| | - Amelia Boughn
- Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue Room 455, Toronto, ON, M5G1X5, Canada
| | - Jessica Saini
- Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue Room 455, Toronto, ON, M5G1X5, Canada
| | - Erin Kennedy
- Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue Room 455, Toronto, ON, M5G1X5, Canada
| | - Helen MacRae
- Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue Room 455, Toronto, ON, M5G1X5, Canada
| | - Anthony de Buck Van Overstraten
- Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue Room 455, Toronto, ON, M5G1X5, Canada.
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Freund MR, Perets M, Horesh N, Yellinek S, Halfteck G, Reissman P, Rosenthal RJ, Wexner SD. Prevalence, diagnosis, and surgical management of complex ileocolic-duodenal fistulas in Crohn's disease. Tech Coloproctol 2022; 26:637-643. [PMID: 35451660 DOI: 10.1007/s10151-022-02616-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- M R Freund
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.,Department of General Surgery, Shaare Zedek Medical Center, Jerusalem, Israel
| | - M Perets
- Department of General Surgery, Shaare Zedek Medical Center, Jerusalem, Israel
| | - N Horesh
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - S Yellinek
- Department of General Surgery, Shaare Zedek Medical Center, Jerusalem, Israel
| | - G Halfteck
- Department of General Surgery, Shaare Zedek Medical Center, Jerusalem, Israel
| | - P Reissman
- Department of General Surgery, Shaare Zedek Medical Center, Jerusalem, Israel
| | - R J Rosenthal
- Department of General Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - S D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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Peyser DK, Carmichael H, Dean A, Baratta VM, D’Andrea AP, Kang G, Bhasin D, Greenstein AJ, Khaitov SK, Steinhagen RM, Sylla P. Early versus delayed ileocolic resection for complicated Crohn's disease: is "cooling off" necessary? Surg Endosc 2022; 36:4290-4298. [PMID: 34988744 PMCID: PMC8730747 DOI: 10.1007/s00464-021-08773-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 10/12/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Ileal Crohn's disease (CD) complicated by intraabdominal abscess, phlegmon, fistula, and/or microperforation is commonly treated with antibiotics, bowel rest, and percutaneous drainage followed by interval ileocolic resection (ICR). This "cool off" strategy is intended to facilitate the safe completion of a one-stage resection using a minimally invasive approach and minimize perioperative complications. There is limited data evaluating the benefits of delayed versus early resection. METHODS A retrospective review of a prospectively maintained inflammatory bowel disease (IBD) database at a tertiary center was queried from 2013-2020 to identify patients who underwent ICR for complicated ileal CD confirmed on preoperative imaging. ICR cohorts were classified as early (≤ 7 days) vs delayed (> 7 days) based on the interval from diagnostic imaging to surgery. Operative approach and 30-day postoperative morbidity were analyzed. RESULTS Out of 474 patients who underwent ICR over the 7-year period, 112 patients had complicated ileal CD including 99 patients (88%) with intraabdominal abscess. Early ICR was performed in 52 patients (46%) at a median of 3 days (IQR 2, 5) from diagnostic imaging. Delayed ICR was performed in 60 patients (54%) following a median "cool off" period of 23 days of non-operative treatment (IQR 14, 44), including preoperative percutaneous abscess drainage in 17 patients (28%). A higher proportion of patients with intraabdominal abscess underwent delayed vs early ICR (57% vs 43%, p = 0.19). Overall, there were no significant differences in the rate of laparoscopy (96% vs 90%), conversion to open surgery (12% vs 17%), rates of extended bowel resection (8% vs 13%), additional concurrent procedures (44% vs 52%), or fecal diversion (10% vs 2%) in the early vs delayed ICR groups. The median postoperative length of stay was 5 days in both groups with an overall 25% vs 17% (p = 0.39) 30-day postoperative complication rate and a 6% vs 5% 30-day readmission rate in early vs delayed ICR groups, respectively. Overall median follow-up time was 14.3 months (IQR 1.2, 24.1) with no difference in the rate of subsequent CD-related intestinal resection (4% vs 5%) between the two groups. CONCLUSIONS In this contemporary series, at a high-volume tertiary referral center, a "cool off" delayed resectional approach was not found to reduce perioperative complications in patients undergoing ICR for complicated ileal Crohn's disease. Laparoscopic ICR can be performed within one week of diagnosis with low rates of conversion and postoperative complications.
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Affiliation(s)
- Daniel K. Peyser
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Heather Carmichael
- Department of General Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Adrienne Dean
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Vanessa M. Baratta
- Department of Surgery, Yale University School of Medicine, New Haven, USA
| | - Anthony P. D’Andrea
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Gurpawan Kang
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Deepika Bhasin
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | | | - Sergey K. Khaitov
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | | | - Patricia Sylla
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029 USA
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11
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Schardey J, Zehl S, Kappenberger AS, Zimmermann P, Beigel F, Schiergens TS, Kasparek MS, Kühn F, Werner J, Wirth U. It is not NOD2 - genetic and clinical risk factors for postoperative complications following ileocolic resection in Crohn's disease. Int J Colorectal Dis 2022; 37:1901-1908. [PMID: 35913516 PMCID: PMC9388399 DOI: 10.1007/s00384-022-04223-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE To evaluate the role of the nucleotide oligomerization domain 2 (NOD2) mutation status and other risk factors for the incidence of postoperative complications after ileocolic resection for Crohn's disease (CD). METHODS Data of 138 patients consecutively undergoing ileocolic resection for CD at a tertiary academic referral center were retrospectively analyzed including single nucleotide polymorphism (SNP) data of the NOD2 gene. Uni- and multivariate regression analysis was performed to identify factors associated with increased risk of severe postoperative complications. RESULTS From 114 patients (83%), the NOD2 mutation status was available. Of these, 60 (53%) had a NOD2 wildtype, whereas eleven (10%) were homozygous for the high risk p.Leu1007fsX1008 (rs2066847) variant. Major postoperative complications occurred in 28 patients (20%). Twenty-seven of these (96%) were intraabdominal septic complications such as anastomotic leakage or abscess. Male gender (P = 0.029; OR 3.052, the duration of CD (time [months] from initial diagnosis of CD to surgery; P = 0.001; OR 1.009), previous abdominal surgery for CD (P = 0.017; OR 3.49), and the presence of enteric fistulas (P = 0.023; OR 3.21) were identified as independent risk factors for major postoperative complications. Homozygosity for the NOD2 high-risk variant p.Leu1007fsX1008 did not show increased postoperative morbidity in the short and long-term outcome. CONCLUSIONS We could detect independent risk factors for major postoperative complications after ileocolic resection for Crohn's disease. However, patients with the high-risk variant p.Leu1007fsX1008 of the NOD2 gene did not show increased postoperative morbidity.
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Affiliation(s)
- Josefine Schardey
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Sophie Zehl
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Alina S. Kappenberger
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Petra Zimmermann
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Florian Beigel
- grid.5252.00000 0004 1936 973XDepartment of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Tobias S. Schiergens
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Michael S. Kasparek
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany ,Department of Visceral Surgery, Josephinum, Munich, Germany
| | - Florian Kühn
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Jens Werner
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Ulrich Wirth
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
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12
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Kellil T, Chaouch MA, Guedich A, Touir W, Dziri C, Zouari K. Surgical features to reduce anastomotic recurrence of Crohn's disease that requires reoperation: a systematic review. Surg Today 2021; 52:542-549. [PMID: 34420112 DOI: 10.1007/s00595-021-02364-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/19/2021] [Indexed: 10/20/2022]
Abstract
Anastomotic recurrence after intestinal resection is one of the main embarrassing problems encountered during Crohn's disease (CD) management. This complication is often associated with an expected consequence, mainly a multiple intestinal resection. This systematic review evaluates published evidence on surgical features to reduce surgical recurrence after bowel resection and provide surgeons with recommendations based on published evidence. We conducted bibliographic research on September 05, 2020, through PubMed, Cochrane database, and Google scholar. We retained meta-analysis, randomized clinical trials, and controlled clinical trials. The strength of clinical data and subsequent recommendations were graded according to the Oxford Centre for Evidence-Based Medicine. Fourteen articles were retained. Early resection reduces surgical relapse and the need for additional medical treatment. There was no difference between conventional and laparoscopic bowel resection. Mesenteric excision seems to reduce surgical recurrence. Stapled side-to-side anastomosis reduces surgical recurrence. However, no difference was observed between Kono-S anastomosis ensure at least similar anastomotic recurrence rate compared to conventional anastomosis. Surgical recurrence was reduced after bowel resection when compared to stricturoplasty. There was no difference between the one and two steps resection. Several surgical features have been investigated. Some of them were unanimously found to be effective in lengthening the disease-free relapse. However, others are still controversial.
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Affiliation(s)
- Tarek Kellil
- Department of Visceral and Digestive Surgery, Fattouma Bourguiba Hospital, University of Monastir, Monastir, Tunisia.
| | - Mohamed Ali Chaouch
- Department of Visceral and Digestive Surgery, Fattouma Bourguiba Hospital, University of Monastir, Monastir, Tunisia
| | - Arwa Guedich
- Department of Gastroenterology, Fattouma Bourguiba Hospital, University of Monastir, Monastir, Tunisia
| | - Wassim Touir
- Department of Visceral and Digestive Surgery, Fattouma Bourguiba Hospital, University of Monastir, Monastir, Tunisia
| | - Chadli Dziri
- Department B of Digestive Surgery, Charles Nicolle Hospital, University of Tunis, Tunis, Tunisia
| | - Khadija Zouari
- Department of Visceral and Digestive Surgery, Fattouma Bourguiba Hospital, University of Monastir, Monastir, Tunisia
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Gordon-Dixon A, Hampal R, Miah A, Webb-Butler S, Lewis W, Ross R, Ghosh N, Grimes C. Does exclusive enteral nutrition reduce the rate of stoma formation in patients requiring ileocolic resection for Crohn's disease? A single center experience. Clin Nutr ESPEN 2021; 44:282-286. [PMID: 34330480 DOI: 10.1016/j.clnesp.2021.05.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 05/13/2021] [Accepted: 05/25/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND AIM Nutrition has a role in achieving and maintaining remission in Crohn's disease. The aim of this study was to determine the impact of a strategy of steroid-avoidance and Exclusive Enteral Nutrition (EEN) for 6 weeks (with a minimum of 4 weeks) in adult patients presenting with acute small bowel Crohn's disease followed by an interval ileocolic resection 4-6 weeks later. METHODS Retrospective review of prospectively collected data. Patients were administered exclusive enteral nutrition (EEN) for at least 4 weeks prior to surgery. RESULTS 24 EEN patients included. Median age of 45 (range 23-73). 17/24 patients tolerated Modulen for at least 4 weeks, 5 were switched to Ensures and 2 a liquid diet. 6 patients underwent surgery earlier than planned. Prior to surgery, there was no change in the mean BMI, albumin increased from a mean of 36 g/L (range 25-43) to 40 g/L (range 30-48). CRP levels decreased by a mean of 35.8 mg/L overall. 19 (79%) of operations were performed laparoscopically. 6 of the cases were re-do operations. All but 3 patients avoided a stoma at the time of the original operation. There were 5 post-operative complications: 1 anastomotic leak in a patient with a BMI of 42, 3 cases of paralytic ileus and 2 wound infections. Median length of stay was 7 days (range 3-76 days). Only 2 patients were readmitted within the 30-day post-operative period. CONCLUSION The pre-operative use of EEN appears to avoid unnecessary stoma formation with acceptable clinical outcomes.
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Affiliation(s)
| | - Rumneek Hampal
- Medway Hospital NHS Foundation Trust, Windmill Way, Gillingham, ME7 5NY, UK.
| | - Anur Miah
- Medway Hospital NHS Foundation Trust, Windmill Way, Gillingham, ME7 5NY, UK.
| | - Shruti Webb-Butler
- Medway Hospital NHS Foundation Trust, Windmill Way, Gillingham, ME7 5NY, UK.
| | - Wendy Lewis
- Medway Hospital NHS Foundation Trust, Windmill Way, Gillingham, ME7 5NY, UK.
| | - Rose Ross
- Medway Hospital NHS Foundation Trust, Windmill Way, Gillingham, ME7 5NY, UK.
| | - Nivedita Ghosh
- Medway Hospital NHS Foundation Trust, Windmill Way, Gillingham, ME7 5NY, UK.
| | - Caris Grimes
- Medway Hospital NHS Foundation Trust, Windmill Way, Gillingham, ME7 5NY, UK.
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14
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Ikeuchi H, Uchino M, Bando T, Horio Y, Kuwahara R, Minagawa T, Goto Y, Kusunoki K, Ikeda M, Beppu N, Takesue Y. Localization of recurrent lesions following ileocolic resection for Crohn's disease. BMC Surg 2021; 21:145. [PMID: 33743665 PMCID: PMC7980576 DOI: 10.1186/s12893-020-00980-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 11/22/2020] [Indexed: 12/13/2022] Open
Abstract
Background Crohn’s disease (CD) recurrence can occur not only at the site of anastomosis but also elsewhere in the bowel following an ileocolic resection (ICR) procedure. The aims of the present study were to assess long-term outcomes of a primary ICR procedure for CD in consecutive patients and examine the location of the reoperation causative lesion. Methods We examined cases of surgery with ICR initially performed at our institution. Those with simultaneous multiple bowel resection or bowel resection with strictureplasty were excluded. Results A total of 169 patients who underwent ICR due to CD were enrolled. The median follow-up period was 12.6 years (range 4–27 years). A reoperation was needed in 45 (26.6%), of whom 14 had lesions causative of the reoperation at other than the anastomotic site. The most common causative lesion location was in the colon rather than the oral side of the small intestine. Furthermore, we investigated the relationship between presence of residual lesions following the initial surgery and lesions causative of reoperation. In the group without residual disease (n = 31), 29.0% (n = 9) had non-anastomotic lesions involved in indications for reoperation, while that was 35.7% (n = 5) in the group with residual disease (n = 14). Conclusions Anastomotic site lesion is not the only causative factor for reoperation following ICR. Regular examinations and applicable treatment with awareness that the cause of reoperation is not limited to the site of anastomosis are important in these cases.
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Affiliation(s)
- Hiroki Ikeuchi
- Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Motoi Uchino
- Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Toshihiro Bando
- Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Yuki Horio
- Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Ryuichi Kuwahara
- Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Tomohiro Minagawa
- Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Yoshiko Goto
- Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Kurando Kusunoki
- Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Masataka Ikeda
- Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Naohito Beppu
- Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Yoshio Takesue
- Division of Infection Control and Prevention, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
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15
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Schineis C, Fenzl T, Aschenbrenner K, Lobbes L, Stroux A, Weixler B, Beyer K, Kamphues C, Kreis ME, Lauscher JC. Stapled intestinal anastomoses are more cost effective than hand-sewn anastomoses in a diagnosis related group system. Surgeon 2020:S1479-666X(20)30146-3. [PMID: 33439832 DOI: 10.1016/j.surge.2020.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 06/10/2020] [Accepted: 09/06/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE Creation of an optimal bowel anastomosis with low postoperative leakage rate is an immanent part of colorectal surgery contributing to recovery, length of hospital stay and overall hospital costs. We aimed to investigate costs of small and large bowel resection, length of hospital stay, anastomotic leakage rate and its risk factors depending on the anastomotic technique. METHODS Retrospective analysis of 198 patients (67 stapled and 131 hand-sewn anastomoses) undergoing elective bowel resection with a single anastomosis without protective ileostomy either stapled or in double-rowed running suture technique between 1st October 2012 and 30th September 2018 at Charité University Hospital Berlin, Campus Benjamin Franklin. We analyzed costs of treatment, total length of hospital stay, rate of anastomotic leakage and possible risk factors for anastomotic leak. RESULTS No significant difference between both anastomotic techniques could be detected for hospital stay (p = 0.754), 30-day-readmission rate (p = 0.827), or anastomotic leakage (p = 606). Neither comorbidities (p = 0.449), underlying disease (p = 0.132), experience of the surgical team (p = 0.828) nor scheduling of the operation (p = 0.531) were associated with anastomotic leakage. Stapled anastomoses took 22 min less operation time than sutured anastomoses (130 vs. 152 min. Median) (p = 0.001). Operations with stapled anastomoses saved 183 € in operation costs and 496 € in overall hospital costs. CONCLUSION Stapled and hand-sewn bowel anastomoses can be performed equally safe without differences in postoperative outcome. No patient, procedure or surgeon related risk factors for anastomotic leakage could be detected. Bowel resections with stapled anastomoses take less time and save operation and overall hospital costs.
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16
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Bolckmans R, Singh S, Ratnatunga K, Wickramasinghe D, Sahnan K, Adegbola S, Kalman D, Jones H, Travis S, Warusavitarne J, Myrelid P, George B. Temporary faecal diversion in ileocolic resection for Crohn's disease: is there an impact on long-term surgical recurrence? Colorectal Dis 2020; 22:430-438. [PMID: 31715062 DOI: 10.1111/codi.14895] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 09/06/2019] [Indexed: 12/12/2022]
Abstract
AIM Temporary faecal diversion after ileocolic resection (ICR) for Crohn's disease reduces postoperative anastomotic complications in high-risk patients. The aim of this study was to assess if this approach also reduces long-term surgical recurrence. METHOD This was a multicentre retrospective review of prospectively maintained databases. Patient demographics, medical and surgical details were collected by three specialist centres. All patients had undergone an ICR between 2000 and 2012. The primary end-point was surgical recurrence. RESULTS Three hundred and twelve patients (80%) underwent an ICR without covering ileostomy (one stage). Seventy-seven (20%) had undergone an ICR with end ileostomy/double-barrel ileostomy/enterocolostomy followed by closure (two stage). The median follow-up was 105 months [interquartile range (IQR) 76-136 months]. The median time to ileostomy closure was 9 months (IQR 5-12 months). There was no significant difference in surgical recurrence between the one- and two-stage groups (18% vs 16%, P = 0.94). We noted that smokers (20% vs 34%, P = 0.01) and patients with penetrating disease (28% vs 52%, P < 0.01) were more likely to be defunctioned. A reduced recurrence rate was observed in the small high-risk group of patients who were smokers with penetrating disease behaviour treated with a two-stage strategy (0/10 vs 4/7, P = 0.12). CONCLUSION Despite having higher baseline risk factors, the results in terms of rate of surgical recurrence over 9 years are similar for patients having a two-stage compared with a one-stage procedure.
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Affiliation(s)
- R Bolckmans
- Department of Colorectal Surgery, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Singh
- Department of Colorectal Surgery, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - K Ratnatunga
- Department of Colorectal Surgery, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - D Wickramasinghe
- Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - K Sahnan
- Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - S Adegbola
- Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - D Kalman
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - H Jones
- Department of Colorectal Surgery, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Travis
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - J Warusavitarne
- Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - P Myrelid
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - B George
- Department of Colorectal Surgery, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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17
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Li Y, Mohan H, Lan N, Wu X, Zhou W, Gong J, Shen B, Stocchi L, Coffey JC, Zhu W. Mesenteric excision surgery or conservative limited resection in Crohn's disease: study protocol for an international, multicenter, randomized controlled trial. Trials 2020; 21:210. [PMID: 32085793 PMCID: PMC7035646 DOI: 10.1186/s13063-020-4105-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 01/22/2020] [Indexed: 12/14/2022] Open
Abstract
Background The structures of the mesentery including adipose tissue, nerves, and lymphatics play an important role in the pathogenesis and disease progression of Crohn’s disease (CD). Conventional surgical resection for CD usually does not involve resecting the mesentery en bloc with the specimen. This contrasts with complete mesocolic excision (CME) in colorectal cancer, which involves radical resection of the mesentery. Preliminary evidence from smaller studies suggests that applying the principle of mesocolic excision to CD surgery may reduce the risk of postoperative recurrence. This randomized controlled trial is designed to test whether applying the principles of mesocolic excision to CD results in reduced postoperative recurrence. It also aims to evaluate intra- and postoperative morbidity between the two approaches. Methods This international, multicenter, randomized controlled trial will randomize patients (n = 116) scheduled to undergo primary ileocolic resection to either receive extensive mesenteric excision (EME) or conventional ileocolic resection with limited mesenteric excision (LME). Five sites will recruit patients in three countries. In the EME group, the mesentery is resected following CME, while avoiding the root region, i.e., 1 cm from the root of the ileocolic artery and vein. In the LME group, the mesentery is retained, i.e., “close shave” or < 3 cm from the border of bowel. The primary end point will be surgical recurrence after surgery. The secondary end points will be the postoperative endoscopic and clinical recurrence, and intra- and postoperative morbidity. Demographics, risk factors, laboratory investigations, endoscopy, postoperative prophylaxis and imaging examination will be assessed. Analysis of the primary outcome will be on an intention-to-treat basis. Discussion If mesocolic excision in CD reduces postoperative disease recurrence and does not increase morbidity, this trial has the potential to change practice and reduce recurrence of CD after surgical resection. Trial registration Clinical Trials.gov, ID: NCT03769922. Registered on February 27, 2019.
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Affiliation(s)
- Yi Li
- Center for Inflammatory Bowel Diseases, Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Helen Mohan
- Department of Surgery, Surgical Professorial Unit, University Hospital Limerick, Limerick, Ireland
| | - Nan Lan
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute Cleveland Clinic, 9500 Euclid Avenue, A30, Cleveland, OH, 44195-0001, USA
| | - Xiaojian Wu
- Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Wei Zhou
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, Hangzhou, China
| | - Jianfeng Gong
- Center for Inflammatory Bowel Diseases, Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Bo Shen
- Section of Inflammatory Bowel Diseases and Center for Interventional IBD, Columbia University Irving Medical Center-NewYork Presbyterian, New York, NY, USA
| | - Luca Stocchi
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute Cleveland Clinic, 9500 Euclid Avenue, A30, Cleveland, OH, 44195-0001, USA.
| | - J Calvin Coffey
- Department of Surgery, Surgical Professorial Unit, University Hospital Limerick, Limerick, Ireland.
| | - Weiming Zhu
- Center for Inflammatory Bowel Diseases, Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
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18
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Aaltonen G, Carpelan-Holmström M, Keränen I, Lepistö A. Surgical recurrence in Crohn's disease: a comparison between different types of bowel resections. Int J Colorectal Dis 2018; 33:473-7. [PMID: 29492657 DOI: 10.1007/s00384-018-2995-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE To compare recurrence frequency and location between different types of bowel resections in Crohn's disease patients. METHODS This was a retrospective study of consecutive patients undergoing bowel resection for Crohn's disease between 2006 and 2016. Type of primary operation was recorded and grouped as ileocolic resection, small bowel resection, segmental colon resection with colocolic anastomosis or colorectal anastomosis, colectomy with ileorectal anastomosis, or end stoma operation. Binary logistic regression was used to compare surgical recurrence frequency between groups. We also investigated how Crohn's disease location at reoperations was related to the primary bowel resection type. RESULTS Altogether, 218 patients with a median follow-up of 4.7 years were included in our study. Reoperation was performed in 42 (19.3%) patients. The risk of reoperation using the ileocolic resection group as reference was the following: small bowel resection (odds ratio (OR) 2.95, 95% confidence interval (CI) 1.01-8.66; P = 0.049), segmental colon resection with colocolic or colorectal anastomosis (OR 6.20, 95% CI 2.04-18.87; P = 0.001), colectomy with ileorectal anastomosis (OR 26.57, 95% CI 2.59-273.01; P = 0.006), and end stoma operation (OR 4.62, 95% CI 1.90-11.26; P = 0.001). In case of surgical recurrence, the reoperation type and location correlated with the primary bowel resection type. CONCLUSIONS Reoperation frequency in Crohn's disease is lower after ileocolic resection than after other types of bowel resections. Surgical recurrence in Crohn's disease tends to maintain the disease location of the primary operation. One third of Crohn's patients undergoing an end stoma operation will still need new bowel resections due to recurrence.
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19
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Moftah M, Nazour F, Cunningham M, Cahill RA. Single port laparoscopic surgery for patients with complex and recurrent Crohn's disease. J Crohns Colitis 2014; 8:1055-61. [PMID: 24589026 DOI: 10.1016/j.crohns.2014.02.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 01/14/2014] [Accepted: 02/06/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Single port laparoscopic surgery (SPLS) is a modified access technique allowing grouping of instruments at a single parietal site. It is intuitively appealing specifically for patients with Crohn's disease (CD) as its minimal invasiveness favors cosmesis and facilitates any future (re)operation. METHODS Consecutive patients presenting either electively or urgently for resectional surgery for CD over a 36 month period were considered for SPLS using, by preference, a transumbilical 'Surgical Glove Port'. Standard, straight laparoscopic instrumentation was used without additional resources. RESULTS Of 33 consecutive, unselected patients, 28 (92%) had their procedure initiated by SPLS including those needing urgent intervention (n=15) and those with prior abdominal operation (n=8), obstruction (n=7), mass (n=6), fistula (n=6) and/or abscess (n=4). The median (range) age and BMI of the patients were 31 (17-69) years and 21.3 (18.6-28) kg/m2 respectively. 31 had ileocolonic resection (6 with recurrent disease) while two underwent segmental colectomy. No-one suffered intraoperative or anastomotic complication. Both conversion (15%) and postoperative complication (13 Clavian-Dindo complications - I: 8; II: 2; IIIa: 3) rates were predominantly reflective of patient and disease complexity. Median (range) postoperative day of discharge was 6 (3-33) overall and 5 (3-18) in those completed by SPLS. There was one early readmission (for infectiouscolitis) and median follow-up is now 21 months. CONCLUSIONS Complex and recurrent Crohn's resections can be performed by SPLS in the majority of patients presenting elective or urgently for surgery. The Surgical Glove Port performs capably and, by minimizing cost, can facilitate broad embrace of this approach.
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Affiliation(s)
- Mohamed Moftah
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Fady Nazour
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | | | - Ronan A Cahill
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland.
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