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Moussally M, Paski SC, Cohen B, Holubar SD. Preoperative Optimization of Crohn's Patients before Abdominopelvic Surgery. Clin Colon Rectal Surg 2025; 38:85-95. [PMID: 39944311 PMCID: PMC11813612 DOI: 10.1055/s-0044-1786380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2025]
Abstract
In this article, we review and identify modifiable risk factors associated with postoperative complications of Crohn's disease. We highlight the importance of factors such as nutrition, corticosteroids, immunomodulators, abscesses, ideal timing of surgery, and biologic and small-molecule therapy on surgical outcomes. Herein, we discuss the strategies for attenuating these risk factors. Special consideration is given to venous thromboembolism prophylaxis in this patient population.
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Affiliation(s)
- Moustafa Moussally
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Shirley C. Paski
- Department of Gastroenterology, Hepatology, and Human Nutrition, Cleveland, Ohio
| | - Benjamin Cohen
- Department of Gastroenterology, Hepatology, and Human Nutrition, Cleveland, Ohio
| | - Stefan D. Holubar
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Violante T, Ferrari D, Sileo A, Sassun R, Ng JC, Mathis KL, McKenna NP, Rumer KK, Larson DW. Assessing robotic-assisted surgery versus open approach in penetrating Crohn's disease: advantages and outcomes in ileocolic resection. Tech Coloproctol 2024; 28:112. [PMID: 39167324 DOI: 10.1007/s10151-024-02985-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 07/13/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION Penetrating Crohn's disease (CD) often necessitates surgical intervention, with the open approach traditionally favored. Robotic-assisted surgery offers potential benefits but remains understudied in this complex patient population. Additionally, the lack of standardized surgical complexity scoring in CD hinders research and comparisons. METHODS We retrospectively analyzed adult patients with penetrating CD who underwent either robotic-assisted ileocolic resection (RICR) or open ileocolic resection (OICR) at our institution from January 2007 to December 2021. We assessed endpoints, including length of stay, complications, readmissions, reoperations, and other perioperative outcomes. RESULTS RICR demonstrated safety outcomes comparable to OICR. Importantly, RICR patients experienced significantly reduced estimated blood loss (p < 0.0001), shorter hospital stays (median 4.5 days versus 6.9 days; p = 0.01), lower surgical site infection rates (0% versus 15.4%; p = 0.01), and decreased 30-day readmission rates (0% versus 15.4%; p = 0.01). Linear regression analysis revealed the need for additional strictureplasties (coefficient: 84.8; p = 0.008), colonic resections (coefficient: 41.7; p = 0.008), and estimated blood loss (coefficient: 0.07; p = 0.002) independently correlated with longer operative times). CONCLUSION Robotic-assisted surgery appears to be a safe and potentially beneficial alternative for the surgical management of penetrating CD, offering advantages in perioperative outcomes reducing length of stay, blood loss, surgical site infection rates, and readmission rates. Further validation with larger cohorts is warranted.
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Affiliation(s)
- T Violante
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
- School of General Surgery, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - D Ferrari
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - A Sileo
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - R Sassun
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - J C Ng
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - K L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - N P McKenna
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - K K Rumer
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - D W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA.
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Sun Z, Cao L, Guo Z, Zhou Y, Zhu W, Li Y. A nomogram to predict stoma creation in elective surgical resection for penetrating Crohn's disease. ANZ J Surg 2024; 94:923-930. [PMID: 38290990 DOI: 10.1111/ans.18872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/14/2023] [Accepted: 01/09/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUNDS The decision to perform a stoma during surgical resection of penetrating Crohn's disease (CD) is a critical consideration. The objective of this study was to identify factors that influence stoma creation and develop a predictive nomogram model to assist surgeons in making optimal surgical decisions. METHODS A retrospective study was conducted at a tertiary center from December 1, 2012, to December 1, 2021, involving consecutive patients with penetrating CD who underwent elective surgical resection. The LASSO regression method was used to select preoperative predictors, and a nomogram was constructed using multivariate logistic regression. The performance of the nomogram was validated in an internal cohort by assessing its discrimination, calibration, and clinical usefulness. RESULTS The study included 405 cases in the training group and 135 cases in the validation group. Nine risk factors for stoma formation were identified, including disease location, fistula resulted from previous anastomosis, absence of preoperative exclusive enteral nutrition support, albumin levels below 35 g/L, C-reactive protein levels above 10 mg/L, hemoglobin levels below 100 g/L, perianal disease, internal fistula, and surgical approach. These risk factors were selected using the LASSO regression method, and a nomogram was developed based on them. The area under the curve and the coefficient of determination (R2) of the nomogram were 0.821 and 0.394, respectively. And the nomogram demonstrated good performance in the validation cohort. CONCLUSIONS The nomogram exhibited good predictive ability for stoma formation during elective surgical resection for penetrating CD, which can assist surgeons in making informed clinical decisions.
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Affiliation(s)
- Zhenya Sun
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yan Zhou
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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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: 0.5] [Reference Citation Analysis] [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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Earlier surgery is associated to reduced postoperative morbidity in ileocaecal Crohn's disease: Results from SURGICROHN – LATAM study. Dig Liver Dis 2022; 55:589-594. [PMID: 37113020 DOI: 10.1016/j.dld.2022.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Early surgical resection is an emerging concept for patients with ileocaecal Crohn's disease (CD). The aim of this study was to compare postoperative outcomes after ileocaecal resections between patients with luminal and complicated CD. METHODS A retrospective analysis of patients operated for ileocaecal CD during an 8-year period in ten tertiary referral academic centres from Latin America was performed. Patients were allocated into 2 groups: those operated for early (luminal) disease (Early Crohn's Disease -ECD-) and for complications of CD (Complicated Crohn's disease -CCD-). A comparative analysis was performed regarding short-term outcomes of surgery, considering overall postoperative complications as main outcome. RESULTS 337 patients were included in the analysis, 60 (17.80%) in the ECD group. Smoking and exposure to perioperative biologic drugs were more prevalent in CCD group. CCD patients had increased requirement of urgent surgery (26.71 vs. 15%, p = 0.056), longer operative time (164.25 vs. 90.53 min, p< 0.01), lower rates of primary anastomosis (90.23 vs. 100%, p = 0.012), increased rate of overall postoperative complications (33.21 vs. 16.67%, p = 0.013), more reoperations (13.36 vs. 3.33%, p = 0.026), and higher rates of major anastomotic fistulas and hospital stay. On multivariable analysis, smoking (p = 0.001,95%CI: 2.59-32.11), operative time (p = 0.022,95%CI:1-1.02), associated procedures (p = 0.036,95%CI:1.09-15.72) and intraoperative complications (p = 0.021,95%CI:1.45-92.31) were independently related to presenting postoperative complications. CONCLUSION Early (luminal) ileocaecal resections were associated to lower rates of overall postoperative complications. Proper timing for surgery, avoiding delays in surgical indication can impact postoperative outcomes.
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The INTESTINE study: INtended TEmporary STomas In crohN's diseasE. Protocol for an international multicentre study. Updates Surg 2022; 74:1691-1696. [PMID: 35962277 PMCID: PMC9481503 DOI: 10.1007/s13304-022-01345-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 07/27/2022] [Indexed: 10/25/2022]
Abstract
Surgery for ileocolonic Crohn's disease can result in temporary or permanent stoma formation which can be associated with morbidity as parastomal and incisional hernias, readmissions due to obstruction or high stoma output, and have a negative impact on quality of life. We propose an international retrospective trainee-led study of the outcomes of temporary stomas in patients with Crohn's disease. We aim to evaluate both the short-term (6 month) and mid-term (18 month) outcomes of temporary stomas in patients with Crohn's Disease. Retrospective, multicentre, observational study including all patients who underwent elective or emergency surgery for ileal, colonic and ileocolonic Crohn's disease during a 4-year study period. Primary outcome is the proportion of patients who still have an ileostomy or colostomy 18 months after the initial surgery. Secondary outcomes: complications related to stoma formation and stoma reversal surgery; time interval between stoma formation and stoma reversal; risk factors for stoma formation and non-reversal of the stoma. We present the study protocol for a trainee-led, multicentre, observational study. Previous research has demonstrated significant heterogeneity surrounding the formation and the timing of reversal surgery in patients having a temporary ileostomy following colorectal cancer surgery, highlighting the need to address these same questions in Crohn's disease, which is the aim of our research.
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Connelly TM, Clancy C, Duraes LC, Cheong JY, Cengiz B, Jia X, Hull T, Holubar SD, Steele SR, Kessler H. Laparoscopic surgery for complex Crohn's disease: perioperative and long-term results from a propensity matched cohort. Int J Colorectal Dis 2022; 37:1885-1891. [PMID: 35869990 DOI: 10.1007/s00384-022-04218-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Laparoscopic surgery for complicated Crohn's (CD) is often technically challenging. Previous studies are limited by the comparison of heterogeneous cohorts of patients undergoing laparoscopic vs open surgery. We aimed to compare perioperative and long-term outcomes of matched patients undergoing laparoscopic and open colonic and ileocolonic resection. Primary outcomes were operative time, blood loss, and complications. Long-term outcomes were subsequent intraabdominal CD surgery, incisional hernia repair, and stoma reversal rates. METHODS Laparoscopic and open CD patients were 1:1 propensity score matched on age, body mass index, sex, indication, ASA grade, prior abdominal surgery, and postoperative Crohn's medication use based on the laparoscopic approach. RESULTS A total of 906 patients underwent surgery for complex CD. After propensity matching, 386 were analyzed (193 open/193 lap, 51.3% male, mean age 33.9 + / - 12.6). Mean follow-up was 9.8 (range 7.9-12.1) years. Length of stay [(LOS) 6 (4, 8) vs 8 (5, 11) days, p < 0.001] and operative time [154 (110, 216) vs 176 (126, 239) min, p = 0.03] were shorter in the laparoscopic group. There was no difference in other complications or mortality. After adjusting for postoperative medications, no association was found between operative approach and subsequent intra-abdominal operation or incisional hernia repair. Laparoscopic patients were less likely to have postoperative sepsis [OR 0.40 (0.18, 0.91), p = 0.03]. CONCLUSION In the setting of complicated Crohn's, in matched cohorts, laparoscopic surgery is associated with reduced operative times and LOS. Mortality, reoperation, and symptomatic hernia rates were equivalent to open surgery. Patients undergoing laparoscopic surgery are less likely to experience postoperative sepsis.
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Affiliation(s)
- Tara M Connelly
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Cillian Clancy
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Leonardo C Duraes
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Ju Yong Cheong
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Bora Cengiz
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Xue Jia
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Tracy Hull
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Stefan D Holubar
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Scott R Steele
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA
| | - Hermann Kessler
- Digestive Disease and Surgery Institute, Dept. of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave./A 30, Cleveland, OH, 44195, USA.
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Luglio G, Tropeano FP, Pagano G, Cricrì M. Editorial: Abdominal and Perianal Fistulizing Crohn's Disease: Imaging, Surgical Techniques and Basic Research. Front Surg 2022; 9:952874. [PMID: 35836609 PMCID: PMC9273927 DOI: 10.3389/fsurg.2022.952874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 05/26/2022] [Indexed: 11/18/2022] Open
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AbuDalu M, Munz Y, Ohana G. Symptomatic ileocolic pseudoaneurysm following laparoscopic ileocecectomy for Crohn's disease: A case report. Int J Surg Case Rep 2022; 94:107059. [PMID: 35413674 PMCID: PMC9018133 DOI: 10.1016/j.ijscr.2022.107059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/20/2022] [Accepted: 04/05/2022] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Crohn's disease is prevalent worldwide. It is an idiopathic, chronic and relapsing disease, characterized by chronic inflammation of any part of the gastrointestinal tract. Vascular involvement rarely occurs in Crohn's patients. However, the chronic inflammatory process leads to structural and functional changes in the vascular endothelium. We present a case of ileocolic artery pseudoaneurysm after laparoscopic ileocecectomy in a Crohn's patient. CASE PRESENTATION We report a case of a 26-years-old male diagnosed with Crohn's disease 4 months prior to an elective laparoscopic ileocecectomy. Before the operation, the patient suffered from severe terminal ileitis and typhlitis with signs of micro perforation. 3 weeks following his discharge, the patient arrived at the ER complaining of severe right lower abdominal pain. Computerized Tomography (CT) scans revealed a 35 mm ileocolic pseudoaneurysm that was treated urgently with coil-embolization via angiography. DISCUSSION Until recently, few reports regarding the involvement of pseudoaneurysm of mesenteric arteries in relation to bowel resection surgeries have been reported. It is believed that the chronic inflammatory process induces a potent effect on the vascular endothelium, leading to thick, inflamed and highly friable mesenteric vessel walls. We propose that the pseudoaneurysm occurred as a result of surgical intervention on a thickened and diseased mesentery artery branch. CONCLUSION Inclusion of mesenteric resection in Crohn patients' undergoing bowel resection may be an innovative way to avoid this complication and to reduce recurrence.
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Affiliation(s)
- M AbuDalu
- Department of General Surgery, Barzilai Medical Center, Ashkelon, Israel.
| | - Y Munz
- Department of General Surgery, Barzilai Medical Center, Ashkelon, Israel.
| | - G Ohana
- Department of General Surgery, Barzilai Medical Center, Ashkelon, Israel.
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Abdalla S, Abd El Aziz MA, Calini G, Saeed H, Merchea A, Shawki S, Behm KT, Larson DW. Perioperative outcomes of minimally invasive ileocolic resection for complicated Crohn disease: Results from a referral center retrospective cohort. Surgery 2022; 172:522-529. [PMID: 35337682 DOI: 10.1016/j.surg.2022.01.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 12/15/2021] [Accepted: 01/28/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Minimally invasive ileocolic resection for complicated Crohn disease, defined as penetrating Crohn disease associated with intra-abdominal fistula, abscess, or phlegmon, is challenging. In addition, the impact of the minimally invasive approach on postoperative outcomes is still debated. This study aimed to compare the intraoperative and postoperative outcomes of minimally invasive ileocolic resection for complicated versus uncomplicated Crohn disease. METHODS A retrospective analysis of all consecutive adult patients with Crohn disease undergoing minimally invasive ileocolic resection from 2014 to 2021 was performed. Perioperative outcomes were compared between patients with complicated Crohn disease (complicated group) and patients without these lesions (uncomplicated group). RESULTS Among the 274 patients undergoing minimally invasive ileocolic resection for Crohn disease, 101 (36.9%) had a robotic approach, and 84 (30.7%) had complicated Crohn disease. Complicated patients were more frequently malnourished (32.1% vs 16.1%, P = .004) and had more frequent previous bowel resections for Crohn disease (22.1% vs 9.5%, P = .002). There were no differences between both groups regarding intraoperative complications (1.1% uncomplicated group vs 2.4% complicated group, P = .463), conversion rate (2.6% uncomplicated group vs 4.8% complicated group, P = .463), postoperative morbidity (27.4% uncomplicated group vs 34.5% complicated group, P = .231), intra-abdominal septic complications (4.2% uncomplicated group vs 7.1% complicated group, P = .309), and length of stay (3.8 ± 2.0 days uncomplicated group vs 4.2 ± 3.0 complicated group, P = .188). CONCLUSION Minimally invasive ileocolic resection for complicated Crohn disease is safe and feasible. Future prospective studies are needed to confirm these results.
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Affiliation(s)
- Solafah Abdalla
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | | | - Giacomo Calini
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | | | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL
| | - Sherief Shawki
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kevin T Behm
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - David W Larson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
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Guyard C, de Ponthaud C, Frontali A, Monsinjon M, Giacca M, Panis Y. C-reactive protein monitoring after ileocecal resection and stoma closure reduces length of hospital stay: a prospective case-matched study in 410 patients with Crohn's disease. Tech Coloproctol 2022; 26:443-451. [PMID: 35239097 DOI: 10.1007/s10151-022-02590-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 01/30/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The aim of this study was to evaluate a C-reactive protein (CRP)-driven monitoring discharge strategy for patients with Crohn's disease (CD) undergoing laparoscopic ileo-cecal resection (ICR) and if needed, temporary stoma closure (SC). METHODS Four hundred and ten patients who underwent laparoscopic ICR for CD: 153 patients (CRP group) between June 2016 and June 2020 at our department, had a CRP-driven monitoring discharge on postoperative day (POD) 3 and were discharged on POD 4 if CRP < 100 mg/L. These patients were matched (according to age, sex, body mass index, type of CD (and stoma or not) to 257 patients who underwent laparoscopic ICR for CD between January 2009 and May 2016, without CRP monitoring (Control group). For SC, 79 patients with CRP monitoring were matched with 88 control patients. Primary outcome was overall length of hospital stay (LHS). Secondary outcomes were discharge on POD 4 for SC and POD 4 and POD 6 for ICR, 3-month postoperative overall morbidity and severe morbidity rates, surgical site infection, readmission rates, and CRP level in cases of morbidity at 3 months. RESULTS For ICR without stoma, mean LHS was significantly shorter in the CRP group than in the control group (6.9 ± 2 days vs 8.3 ± 6 days, p = 0.017). Discharge occurred on POD 6 (or before) in 73% of the patients (CRP group) vs 60% (Control group) (p = 0.027). For ICR with stoma, LHS was 8 days for both groups (p = 0.612). For SC, LHS was significantly shorter in the CRP group than in the control group (5.5 ± 3 days vs 7.1 ± 4 days; p = 0.002). Discharge occurred on POD 4 in 62% (CRP group) vs 30% (Control) (p = 0.003). Postoperative 3-month overall and severe morbidity, and rehospitalization rates were similar between groups. CONCLUSIONS CRP-driven monitoring discharge strategy after laparoscopic ICR for CD is associated with a significant reduction of LHS, without increasing morbidity, reoperation or rehospitalisation rates.
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Affiliation(s)
- C Guyard
- Department of Colorectal Surgery, DMU DIGEST, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University of Paris, 100 boulevard du Général Leclerc, 92118, Clichy, France
| | - C de Ponthaud
- Department of Colorectal Surgery, DMU DIGEST, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University of Paris, 100 boulevard du Général Leclerc, 92118, Clichy, France
| | - A Frontali
- Department of Colorectal Surgery, DMU DIGEST, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University of Paris, 100 boulevard du Général Leclerc, 92118, Clichy, France
| | - M Monsinjon
- Department of Colorectal Surgery, DMU DIGEST, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University of Paris, 100 boulevard du Général Leclerc, 92118, Clichy, France
| | - M Giacca
- Department of Colorectal Surgery, DMU DIGEST, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University of Paris, 100 boulevard du Général Leclerc, 92118, Clichy, France
| | - Y Panis
- Department of Colorectal Surgery, DMU DIGEST, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University of Paris, 100 boulevard du Général Leclerc, 92118, Clichy, France.
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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: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [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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Ogino T, Sekido Y, Hata T, Miyoshi N, Takahashi H, Uemura M, Yamamoto H, Doki Y, Eguchi H, Mizushima T. The safety and feasibility of laparoscopic redo surgery for recurrent Crohn’s disease: A comparative clinical study of over 100 consecutive patients. Ann Gastroenterol Surg 2021; 6:405-411. [PMID: 35634187 PMCID: PMC9130919 DOI: 10.1002/ags3.12534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/05/2021] [Accepted: 11/29/2021] [Indexed: 11/10/2022] Open
Affiliation(s)
- Takayuki Ogino
- Department of Gastroenterological Surgery Osaka University Graduate School of Medicine Suita Japan
- Department of Therapeutics for Inflammatory Bowel Diseases Osaka University Graduate School of Medicine Suita Japan
| | - Yuki Sekido
- Department of Gastroenterological Surgery Osaka University Graduate School of Medicine Suita Japan
| | - Tsuyoshi Hata
- Department of Gastroenterological Surgery Osaka University Graduate School of Medicine Suita Japan
| | - Norikatsu Miyoshi
- Department of Gastroenterological Surgery Osaka University Graduate School of Medicine Suita Japan
| | - Hidekazu Takahashi
- Department of Gastroenterological Surgery Osaka University Graduate School of Medicine Suita Japan
| | - Mamoru Uemura
- Department of Gastroenterological Surgery Osaka University Graduate School of Medicine Suita Japan
| | - Hirofumi Yamamoto
- Department of Gastroenterological Surgery Osaka University Graduate School of Medicine Suita Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery Osaka University Graduate School of Medicine Suita Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery Osaka University Graduate School of Medicine Suita Japan
| | - Tsunekazu Mizushima
- Department of Gastroenterological Surgery Osaka University Graduate School of Medicine Suita Japan
- Department of Therapeutics for Inflammatory Bowel Diseases Osaka University Graduate School of Medicine Suita Japan
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14
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Iesalnieks I, Bittermann T, Schlitt HJ, Hackl C. Reversal of end-ileostomy in patients with Crohn's disease. Int J Colorectal Dis 2021; 36:2119-2125. [PMID: 33929586 DOI: 10.1007/s00384-020-03823-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE End-ileostomy after two-staged ileocolic resection is frequently performed in Crohn's disease patients at high risk for postoperative complications. However, there is paucity on data regarding the morbidity after the stoma reversal. METHODS One hundred thirty patients undergoing closure of end-ileostomy between 1994 and 2016 were included. Data collection was retrospective in 11 first, and it was prospective in 119 last patients. Anastomotic complications were defined as anastomotic leak, perianastomotic abscess, and perianastomotic peritonitis. RESULTS The median interval between ileostomy construction and reversal was 4.0 months. Ninety-seven of 121 patients with available data (80%) gained weight between both surgeries. Hemoglobin level increased between surgeries in 107 patients (85%). Fifteen patients (11.5%) received parenteral fluid substitution or parenteral nutrition between both surgeries. There were 37 hospital readmissions during the time between stoma construction and reversal (29%). After ileostomy reversal, 14 patients developed anastomotic complications (11%). By multivariate regression analysis, preoperative steroid intake (hazard ratio 4.5, 95% CI: 1.11-18.0, p = 0.035) and hospital readmission for infectious complications (HR 4.5, 95% CI: 1.11-18.0, p = 0.035) were statistically significantly associated with an increased risk to develop postoperative anastomotic complications. There were no postoperative deaths. CONCLUSION Closure of end-ileostomy could be complicated by some serious morbidity. These risks should be taken into consideration weighing carefully between the one- and two-stage ileocolic resection in Crohn's disease patients.
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Affiliation(s)
- I Iesalnieks
- Department of Surgery, University of Regensburg, Regensburg, Germany. .,Department of Surgery, Klinik München Bogenhausen, Englschalkinger Str. 77, 81925, Munich, Germany.
| | - T Bittermann
- Department of Surgery, University of Regensburg, Regensburg, Germany
| | - H J Schlitt
- Department of Surgery, University of Regensburg, Regensburg, Germany
| | - C Hackl
- Department of Surgery, University of Regensburg, Regensburg, Germany
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15
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Gunnells D, Cannon J. Robotic Surgery in Crohn's Disease. Clin Colon Rectal Surg 2021; 34:286-291. [PMID: 34512197 DOI: 10.1055/s-0041-1729862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Surgery for Crohn's disease presents unique challenges secondary to the inflammatory nature of the disease. While a minimally invasive approach to colorectal surgery has consistently been associated with better patient outcomes, adoption of laparoscopy in Crohn's disease has been limited due to these challenges. Robotic assisted surgery has the potential to overcome these challenges and allow more complex patients to undergo a minimally invasive operation. Here we describe our approach to robotic assisted surgery for terminal ileal Crohn's disease.
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Affiliation(s)
- Drew Gunnells
- Division of Gastrointestinal Surgery, University of Alabama, Birmingham, Alabama
| | - Jamie Cannon
- Division of Gastrointestinal Surgery, University of Alabama, Birmingham, Alabama
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16
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Yoon YS, Stocchi L, Holubar S, Aiello A, Shawki S, Gorgun E, Steele SR, Delaney CP, Hull T. When should we add a diverting loop ileostomy to laparoscopic ileocolic resection for primary Crohn's disease? Surg Endosc 2021; 35:2543-2557. [PMID: 32468260 DOI: 10.1007/s00464-020-07670-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 05/21/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The aims of this study were to determine risk factors for morbidity associated with laparoscopic ileocolic resection (LICR) for Crohn's disease (CD) and whether the addition of a diverting ileostomy is associated with reduced morbidity. METHODS Patients undergoing LICR for primary CD at our institution from 2005 to 2015 included in a prospectively maintained database were assessed. The decision to perform a diverting ileostomy was left at the discretion of the operating surgeon. Demographics, disease-related, and treatment-related variables were evaluated using univariate and multivariate analyses as possible factors associated with diverting ileostomy creation and 30-day perioperative septic complications (anastomotic leaks and/or abscess). Use of any immunosuppressive medication was defined as use of steroids, biologics, and immunomodulators either alone or in combination. RESULTS For 409 patients, mortality was nil, overall morbidity rate was 40.6%, conversion rate 9.3%, and septic morbidity rate 7.6%. A diverting stoma was created in 22% of cases and was independently associated with BMI < 18.5 kg/m2 (P = 0.001), low serum albumin levels (P = 0.006), and longer operative time (P = 0.003). Use of any immunosuppressive medication was the only variable independently associated with septic complications, both in the overall population (OR 2.7, P = 0.036) and in the subgroup of undiverted patients (OR 3.1, P = 0.031). There was no association between septic morbidity and ileostomy creation, anastomotic configuration, penetrating disease, combined procedures (other resection or strictureplasty), BMI, albumin levels, and operative times. CONCLUSIONS LICR is safe in selected cases of complex penetrating disease, including when combined procedures are necessary. Our data are unable to prove that a diverting stoma is associated with reduced morbidity.
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Affiliation(s)
- Yong Sik Yoon
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Colorectal Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Luca Stocchi
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Desk A30, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alexandra Aiello
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sherief Shawki
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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17
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Abdalla S, Benoist S, Maggiori L, Zerbib P, Lefevre JH, Denost Q, Germain A, Cotte E, Beyer-Berjot L, Corte H, Desfourneaux V, Rahili A, Duffas JP, Pautrat K, Denet C, Bridoux V, Meurette G, Faucheron JL, Loriau J, Guillon F, Vicaut E, Panis Y, Brouquet A. Impact of preoperative enteral nutritional support on postoperative outcome in patients with Crohn's disease complicated by malnutrition: Results of a subgroup analysis of the nationwide cohort registry from the GETAID Chirurgie group. Colorectal Dis 2021; 23:1451-1462. [PMID: 33624371 DOI: 10.1111/codi.15600] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 11/27/2020] [Accepted: 01/06/2021] [Indexed: 12/12/2022]
Abstract
AIM Postoperative morbidity is high in patients operated on for Crohn's disease (CD) complicated by malnutrition. This study aimed to evaluate the impact of preoperative enteral nutritional support (PENS) on postoperative outcome in patients with CD complicated by malnutrition included in a prospective nationwide cohort. METHOD Malnutrition was defined as body mass index <18 kg/m2 and/or albuminaemia <30 g/L and/or weight loss >10%. Failure of PENS was defined as the requirement for additional preoperative parenteral nutrition to PENS. Univariate analysis of the risk factors for PENS failure was performed. Propensity score matching (PSM) was used to compare the outcomes between 'upfront surgery' and 'PENS' groups. The primary endpoint was the rate of intra-abdominal septic morbidity and/or temporary defunctioning stoma. RESULTS Among 592 patients included, 149 were selected. In the intention-to-treat population including 20 (13.4%) patients with PENS failure after PSM, 78 'upfront surgery' and 71 'PENS'-matched patients were compared, with no significant difference in the primary endpoint. Perforating CD and preoperative intra-abdominal fistula were associated with PENS failure [37.5 vs 16.1% (P = 0.047) and 41.2% vs 16.2% (P = 0.020), respectively]. After exclusion of these 20 patients, PSM was used to compare 45 'upfront surgery' and 51 'PENS'-matched patients, with a significantly decreased rate of intra-abdominal septic complications and/or temporary defunctioning stoma in the PENS group (19.6 vs 42.2%, P = 0.016). CONCLUSION Preoperative enteral nutritional support is associated with a trend but no conclusive evidence of a reduction in intra-abdominal septic complications and/or requirement for defunctioning stoma. Patients with perforating CD complicated with malnutrition are at risk of PENS failure.
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Affiliation(s)
- Solafah Abdalla
- Department of Digestive Surgery and Surgical Oncology, Hôpital Bicêtre, Université Paris Saclay, APHP, Le Kremlin Bicêtre, France.,UMR 1195, Institut National de la Santé et de la Recherche Médicale, Hôpital de Bicêtre, Université Paris Saclay, Le Kremlin Bicêtre, France
| | - Stéphane Benoist
- Department of Digestive Surgery and Surgical Oncology, Hôpital Bicêtre, Université Paris Saclay, APHP, Le Kremlin Bicêtre, France
| | - Léon Maggiori
- Department of Digestive Surgery, Hôpital Saint-Louis, Université Paris VII, APHP, Paris, France
| | | | - Jérémie H Lefevre
- Department of Digestive Surgery, Hôpital Saint Antoine, Université Paris Sorbonne, APHP, Paris, France
| | - Quentin Denost
- Department of Digestive Surgery, CHU Bordeaux, Bordeaux, France
| | | | - Eddy Cotte
- Department of Digestive Surgery, CHU Lyon-Sud, Pierre-Bénite, France
| | | | - Hélène Corte
- Department of Digestive Surgery, Hôpital Saint-Louis, Université Paris VII, APHP, Paris, France
| | | | - Amine Rahili
- Department of Digestive Surgery, CHU Nice, Nice, France
| | - Jean-Pierre Duffas
- Department of Digestive Surgery, CHU Toulouse-Rangueil, Toulouse, France
| | - Karine Pautrat
- Department of Digestive Surgery, Hôpital Lariboisière, Université Paris VII, APHP, Paris, France
| | - Christine Denet
- Department of Digestive Surgery, Institut Mutualiste Montsouris, Paris, France
| | | | | | | | - Jérôme Loriau
- Department of Digestive Surgery, Hôpital Saint Joseph, Paris, France
| | - Françoise Guillon
- Department of Digestive Surgery, CHU Montpellier, Montpellier, France
| | - Eric Vicaut
- Unité de Recherche Clinique, Hôpital Fernand Widal, Université Paris VII, AP-HP, Paris, France
| | - Yves Panis
- Department of Colorectal Surgery, Hôpital Beaujon, Université Paris VII, APHP, Clichy, France
| | - Antoine Brouquet
- Department of Digestive Surgery and Surgical Oncology, Hôpital Bicêtre, Université Paris Saclay, APHP, Le Kremlin Bicêtre, France.,UMR 1195, Institut National de la Santé et de la Recherche Médicale, Hôpital de Bicêtre, Université Paris Saclay, Le Kremlin Bicêtre, France
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18
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Fahim M, Dijksman LM, Derksen WJM, Bloemen JG, Biesma DH, Smits AB. Prospective multicentre study of a new bowel obstruction treatment in colorectal surgery: Reduced morbidity and mortality. Eur J Surg Oncol 2021; 47:2414-2420. [PMID: 34023165 DOI: 10.1016/j.ejso.2021.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/06/2021] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Bowel obstruction patients are at increased risk of emergency surgery and have poor nutritional and physical conditions. These patients could benefit from prehabilitation and prevention of emergency surgery. This study assessed the effect of a multimodal obstruction treatment for bowel obstruction patients in colorectal surgery on the risk of emergency surgery and postoperative morbidity and mortality. MATERIALS AND METHODS This multicenter observational cohort study included all consecutive bowel obstruction patients who received obstruction treatment (obstruction protocol) in the period 2019-2020 in two Dutch hospitals. Benign and malignant causes of bowel obstruction were included. Treatment consisted of 1. dietary adjustments, 2. postponing surgery for three weeks, 3. laxatives, and 4. prehabilitation. We compared emergency surgery and postoperative morbidity and mortality rates to known rates from the literature. RESULTS Eighty-nine patients were included: obstruction treatment was successful in 77 patients (87%) who underwent elective surgery and unsuccessful in 12 patients (13%) who underwent emergency surgery. Sixty-six (74%) had colorectal cancer, and 22 (25%) had benign disease. Thirty-day mortality of 0% in our study was significantly lower than the national average of 4% in colorectal cancer patients in the Netherlands (p = 0.049). Anastomotic leakage rate was 3%, severe complications (Clavien-Dindo ≥ III) 8%, and bowel perforation 0%. These rates did not differ significantly from rates reported in literature. CONCLUSION The obstruction treatment prevented emergency surgery in most patients with bowel obstruction and reduced postoperative morbidity and mortality. The obstruction treatment seems to be a safe and efficient alternative to emergency surgery.
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Affiliation(s)
- M Fahim
- Department of Surgery, St Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands; Department of Value-Based Healthcare, St. Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands.
| | - L M Dijksman
- Department of Value-Based Healthcare, St. Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands
| | - W J M Derksen
- Department of Surgery, St Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands
| | - J G Bloemen
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623, EJ Eindhoven, the Netherlands
| | - D H Biesma
- Department of Surgery, St Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands; Department of Value-Based Healthcare, St. Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands
| | - A B Smits
- Department of Surgery, St Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands
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Nevo Y, Zippel D, Segev L, Ben Yaacov A, Meron Eldar S, Hazzan D. Totally Laparoscopic Ileocolic Resection for Complex Enterovisceral Fistulas in Crohn's Disease: A Comparative Study. Surg Laparosc Endosc Percutan Tech 2021; 31:539-542. [PMID: 33710102 DOI: 10.1097/sle.0000000000000928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 10/07/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION In primary Crohn's disease (CD), laparoscopic ileocolic resection has been shown to be both feasible and safe, and is associated with improved outcomes in terms of postoperative morbidity and length of hospital stay. However, it is unclear whether the laparoscopic approach can be routinely proposed as a safe procedure for patients with complex enterovisceral fistulas.The aim of this study is to assess the feasibility and safety of laparoscopic surgery for complex enterovisceral fistulas, and compare it with CD patients who underwent primary laparoscopic ileocolic resection. PATIENTS AND METHODS All patients who underwent laparoscopic primary ileocolic resection (LICR) for complex enterovisceral fistulas between July 2006 and July 2017 were included. They were compared with all consecutive patients who underwent LICR for nonfistulizing CD in the same period of time. Patients with previous bowel resections or recurrent disease were excluded. RESULTS Nineteen patients with 20 enterovisceral fistulas (group I) were compared with 61 patients who underwent LICR for nonfistulizing disease (group II). There were no differences between the groups in age, sex, preoperative body mass index, nutritional status, and American Society of Anesthesiology score. There was no conversion to open surgery in both groups.There were no significant differences between groups in terms of operative time [120 (range: 65 to 232) vs. 117 (range: 62 to 217) min, P=0.7], hospital stay [6 (5 to 8) vs. 7 (5 to 65) days, P=0.56], overall morbidity 26.3% versus 16.4% (P=0.33), major morbidity (Clavien-Dindo >3) 15.7% versus 10% (P=0.66) and reoperation rates 5.3% versus 4.9% (P=0.9). There was no mortality in both groups. CONCLUSIONS Our experience shows that the laparoscopic approach for complex enterovisceral fistulas in selected CD patients is both feasible and safe in the hands of experienced inflammatory bowel disease surgeons with extensive expertise in laparoscopic surgery. Larger study cohorts are needed to confirm these findings.
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Affiliation(s)
- Yehonatan Nevo
- Department of Surgery C
- Minimally Invasive and Robotic Surgery, Sheba Medical Center, Tel Hashomer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Douglas Zippel
- Department of Surgery C
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lior Segev
- Department of Surgery C
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Almog Ben Yaacov
- Department of Surgery C
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shai Meron Eldar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Hazzan
- Department of Surgery C
- Minimally Invasive and Robotic Surgery, Sheba Medical Center, Tel Hashomer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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20
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Collard MK, Benoist S, Maggiori L, Zerbib P, Lefevre JH, Denost Q, Germain A, Cotte E, Beyer-Berjot L, Corté H, Desfourneaux V, Rahili A, Duffas JP, Pautrat K, Denet C, Bridoux V, Meurette G, Faucheron JL, Loriau J, Souche R, Vicaut E, Panis Y, Brouquet A. A Reappraisal of Outcome of Elective Surgery After Successful Non-Operative Management of an Intra-Abdominal Abscess Complicating Ileocolonic Crohn's Disease: A Subgroup Analysis of a Nationwide Prospective Cohort. J Crohns Colitis 2021; 15:409-418. [PMID: 33090205 DOI: 10.1093/ecco-jcc/jjaa217] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Few prospective data exist on outcomes of surgery in Crohn's disease [CD] complicated by an intra-abdominal abscess after resolution of this abscess by antibiotics optionally combined with drainage. METHODS From 2013 to 2015, all patients undergoing elective surgery for CD after successful non-operative management of an intra-abdominal abscess [Abscess-CD group] were selected from a nationwide multicentre prospective cohort. Resolution of the abscess had to be computed tomography/magnetic resonance-proven prior to surgery. Abscess-CD group patients were 1:1 matched to uncomplicated CD [Non-Penetrating-CD group] using a propensity score. Postoperative results and long-term outcomes were compared between the two groups. RESULTS Among 592 patients included in the registry, 63 [11%] fulfilled the inclusion criteria. The abscess measured 37 ± 20 mm and was primarily managed with antibiotics combined with drainage in 14 patients and nutritional support in 45 patients. At surgery, a residual fluid collection was found in 16 patients [25%]. Systemic steroids within 3 months before surgery [p = 0.013] and the absence of preoperative enteral support [p = 0.001] were identified as the two significant risk factors for the persistence of a fluid collection. After propensity score matching, there was no significant difference between the Abscess-CD and Non-Penetrating-CD groups in the rates of primary anastomosis [84% vs 90% respectively, p = 0.283], overall [28% vs 15% respectively, p = 0.077] and severe postoperative morbidity [7% vs 7% respectively, p = 1.000]. One-year recurrence rates for endoscopic recurrence were 41% in the Abscess-CD and 51% in the Non-Penetrating-CD group [p = 0.159]. CONCLUSIONS Surgery after successful non-operative management of intra-abdominal abscess complicating CD provides good early and long-term outcomes.
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Affiliation(s)
- M K Collard
- Digestive Surgery Department, Bicêtre Hospital, APHP, Paris-Sud University, Le Kremlin-Bicetre, France
| | - S Benoist
- Digestive Surgery Department, Bicêtre Hospital, APHP, Paris-Sud University, Le Kremlin-Bicetre, France
| | - L Maggiori
- Department of Colorectal Surgery, Beaujon Hospital, APHP, Paris VII University, Clichy, France
| | - P Zerbib
- Digestive Surgery Department, University Hospital of Lille, Lille, France
| | - J H Lefevre
- Digestive Surgery Department, Saint-Antoine Hospital Saint-Antoine, APHP, Paris VI University, Paris, France
| | - Q Denost
- Digestive Surgery Department, Saint-Andre University Hospital, Bordeaux, France
| | - A Germain
- Digestive Surgery Department, University Hospital of Nancy, Nancy, France
| | - E Cotte
- Digestive Surgery Department, Lyon-Sud University Hospital, Pierre-Benite, France
| | - L Beyer-Berjot
- Digestive Surgery Department, Marseille-Nord University Hospital, Marseille, France
| | - H Corté
- Digestive Surgery Department, Saint-Louis Hospital, Paris VII University, Paris, France
| | - V Desfourneaux
- Digestive Surgery Department, University Hospital of Rennes, Rennes, France
| | - A Rahili
- Digestive Surgery Department, University Hospital of Nice, Nice, France
| | - J P Duffas
- Digestive Surgery Department, Rangueil University Hospital, Toulouse, France
| | - K Pautrat
- Digestive Surgery Department, Lariboisiere Hospital, Paris VII University, Paris, France
| | - C Denet
- Digestive Surgery Department, Montsouris Institute, Paris, France
| | - V Bridoux
- Digestive Surgery Department, University Hospital of Rouen, Rouen, France
| | - G Meurette
- Digestive Surgery Department, University Hospital of Nantes, Nantes, France
| | - J L Faucheron
- Digestive Surgery Department, Digestive Surgery Department, University Hospital of Grenoble, La Tronche, France
| | - J Loriau
- Digestive Surgery Department, Saint-Joseph Hospital, Paris, France
| | - R Souche
- Digestive Surgery Department, University Hospital of Montpellier, Montpellier, France
| | - E Vicaut
- Department of Clinical Research, Fernand Widal Hospital, APHP, Paris VII, Paris, France
| | - Y Panis
- Department of Colorectal Surgery, Beaujon Hospital, APHP, Paris VII University, Clichy, France
| | - A Brouquet
- Digestive Surgery Department, Bicêtre Hospital, APHP, Paris-Sud University, Le Kremlin-Bicetre, France
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21
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Complications after intestinal resection in Crohn's disease: laparoscopic versus conventional approach. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2013.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Abstract
Background significant advances in medical therapy for Crohn's disease (CD) occurred in the last 12 years, mainly due to the introduction of anti-TNF therapy. Laparoscopic colorectal surgery represented the most important advance on surgical treatment in the management of CD, as it also had developed in the treatment of other conditions. There is a tendency for lower complication rates after laparoscopic bowel resections as compared to open surgery. The aim of this study was to analyze and compare the complication rates after bowel resections for CD between the two approaches in a Brazilian case series.
Methods this was a retrospective longitudinal study, including CD patients submitted to bowel resections from a single Brazilian Inflammatory Bowel Diseases (IBD) referral center, treated between January 2008 and June 2012 with laparoscopic approach (LA) or conventional approach (CA).
Variables analyzed age at surgery, gender, Montreal classification, smoking, concomitant medication, type of surgery, surgical approach, presence and type of complication up to 30 days after the procedures. Readmission and reoperation rates, as well as mortality, were also analyzed. Patients were allocated in two groups regarding the type of procedure (LA or CA), and complication rates and characteristics were compared. Statistical analysis was performed with Mann-Whitney test (quantitative variables) and chi-square test (qualitative variables), with p < 0.05 considered significant.
Results a total of 46 patients (25 men) were included (16 submitted to LA), with mean age of 38.1 (± 12.7) years. The groups were considered homogeneous according to age, gender, CD location, perianal disease and concomitant medications. There were more patients with fistulizing CD on the CA group (p = 0.029). The most common procedure performed was ileocolic resection on both groups (56.7% of the CA and 75% of the LA patients – p = 0.566). Overall, total complications (surgical and medical, including minor and major issues) occurred in 60% (18/30) of the CA group and 12.5% (2/16) of the LA group (p = 0.002). Wound infection was the most frequent complication (10/30 on CA and 1/16 on the LA groups). There were 3 deaths in the CA group. Specific analysis of each complication did not demonstrate any difference between the groups regarding abdominal sepsis, urinary tract infections, pneumonia, readmission, reoperations and deaths (p = 0.074).
Conclusions there was a higher complication rate in patients operated with CA as compared to LA. This was probably due to patient selection for the laparoscopic approach, with severe cases, mostly due to fistulizing abdominal CD, being operated mainly by open surgery. LA tends to be the recommended approach in most cases of non-complicated CD.
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22
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Hao X, Feng T, Yang Y, Shi Y, Jing R, Liu S, Luo Y, Qiao Y, Zhong M, Yu M. Laparoscopic bowel resection combined with infliximab treatment (LaRIC) versus infliximab for terminal ileitis in Crohn's disease: a randomised, controlled, open-label trial. BMJ Open 2020; 10:e038429. [PMID: 33199421 PMCID: PMC7670938 DOI: 10.1136/bmjopen-2020-038429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 09/15/2020] [Accepted: 09/26/2020] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Crohn's disease is a chronic inflammatory disease of the gastrointestinal tract with an increasing incidence and prevalence worldwide. The early use of anti--tumour necrosis factor agents, such as infliximab, in patients with an aggressive form of Crohn's disease has become part of routine practice. However, infliximab has limitations, and early surgery might benefit patients more. The objective of this study was to compare laparoscopic bowel resection with infliximab treatment in patients with moderately or severely active Crohn's disease with respect to endoscopic remission. The laparoscopic bowel resection combined with infliximab treatment trial is the first randomised controlled trial to demonstrate if early surgery can improve the outcome of patients with Crohn's disease with limited non-stricturing disease treated with infliximab. METHODS AND ANALYSIS This is a randomised, open-label, controlled trial at Renji Hospital. In this study, a total of 106 adult patients aged 18-80 years with moderately or severely active and steroid-dependent or steroid-resistant Crohn's disease of the distal ileum will be randomly assigned in a 1:1 ratio to the control and surgery groups. The primary outcome is 12-month endoscopic remission measured by the Simple Endoscopic Score for Crohn's Disease in the control group and the Rutgeerts score in the surgery group. The secondary outcomes are clinical remission, surgery rate, quality of life, Crohn's disease-related medical costs and Crohn's disease-related morbidity. The patients will be followed up every 6 months after randomisation through intestinal magnetic resonance enterography and colonoscopy for either 3 years or until clinical remission. ETHICS AND DISSEMINATION All participants will provide informed consent. The protocol has been approved by the Medical Ethical Committee of the Academic Medical Center in Shanghai (No KY2019-180). Results will be disseminated through peer-reviewed journals and scientific conference presentations. TRIAL REGISTRATION NUMBER ChiCTR2000029323.
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Affiliation(s)
- Xiuxiu Hao
- Department of Gastrointestinal Surgery, Shanghai Jiao Tong University School of Medicine Affiliated to Renji Hospital, Shanghai, China
| | - Tienan Feng
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yang Yang
- Department of Gastroenterology, Daping Hospital, Army Medical University, Chongqing, China
| | - Yuan Shi
- Department of Gastrointestinal Surgery, Shanghai Jiao Tong University School of Medicine Affiliated to Renji Hospital, Shanghai, China
| | - Ran Jing
- Department of Gastrointestinal Surgery, Shanghai Jiao Tong University School of Medicine Affiliated to Renji Hospital, Shanghai, China
| | - Sailiang Liu
- Department of Gastrointestinal Surgery, Shanghai Jiao Tong University School of Medicine Affiliated to Renji Hospital, Shanghai, China
| | - Yang Luo
- Department of Gastrointestinal Surgery, Shanghai Jiao Tong University School of Medicine Affiliated to Renji Hospital, Shanghai, China
| | - Yuqi Qiao
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Inflammatory Bowel Disease Research Center, Shanghai Institute of Digestive Disease, Shanghai Jiao Tong University School of Medicine Affiliated to Renji Hospital, Shanghai, China
| | - Ming Zhong
- Department of Gastrointestinal Surgery, Shanghai Jiao Tong University School of Medicine Affiliated to Renji Hospital, Shanghai, China
| | - Minhao Yu
- Department of Gastrointestinal Surgery, Shanghai Jiao Tong University School of Medicine Affiliated to Renji Hospital, Shanghai, China
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23
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Lightner AL, Ashburn JH, Brar MS, Carvello M, Chandrasinghe P, van Overstraeten ADB, Fleshner PR, Gallo G, Kotze PG, Holubar SD, Reza LM, Spinelli A, Strong SA, Tozer PJ, Truong A, Warusavitarne J, Yamamoto T, Zaghiyan K. Fistulizing Crohn's disease. Curr Probl Surg 2020; 57:100808. [PMID: 33187597 DOI: 10.1016/j.cpsurg.2020.100808] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, OH.
| | - Jean H Ashburn
- Department of Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC
| | - Mantaj S Brar
- Department of Surgery, Mount Sinai Hospital, Toronto, ON; Zane Cohen Center for Digestive Diseases, Toronto, ON; Department of Surgery, University of Toronto, ON
| | - Michele Carvello
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | | | - Anthony de Buck van Overstraeten
- Department of Surgery, Mount Sinai Hospital, Toronto, ON; Zane Cohen Center for Digestive Diseases, Toronto, ON; Department of Surgery, University of Toronto, ON
| | | | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Paulo Gustavo Kotze
- IBD Outpatient Clinics, Colorectal Surgery Unit, Catholic University of Parana (PUCPR), Curitiba, Brazil
| | - Stefan D Holubar
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, OH
| | - Lillian M Reza
- Fistula research Unit, St Mark's Hospital and academic institute, London, UK
| | - Antonino Spinelli
- Humanitas Clinical and Research Center, Colon and Rectal Surgery Unit, Italy; Humanitas University, Department of Biomedical Sciences, Italy
| | - Scott A Strong
- Department of Gastrointestinal Surgery, Northwestern University, Chicago, IL
| | - Philip J Tozer
- Fistula research Unit, St Mark's Hospital and academic institute, London, UK
| | - Adam Truong
- Department of Surgery, Cedars Sinai, Los Angeles, CA
| | | | - Takayuki Yamamoto
- Inflammatory Bowel Disease Center & Department of Surgery, Yokkaichi Hazu Medical Center, Yokkaichi, Japan
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Lightner AL. Applying Endoscopic Interventions to Inflammatory Bowel Disease-Related Strictures. CROHN'S & COLITIS 360 2020; 2:otaa066. [PMID: 36777749 PMCID: PMC9802366 DOI: 10.1093/crocol/otaa066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA,Address correspondence to: Amy L. Lightner, MD, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195 ()
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25
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Pellino G, Keller DS, Sampietro GM, Angriman I, Carvello M, Celentano V, Colombo F, Di Candido F, Laureti S, Luglio G, Poggioli G, Rottoli M, Scaringi S, Sciaudone G, Sica G, Sofo L, Leone S, Danese S, Spinelli A, Delaini G, Selvaggi F. Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease. Tech Coloproctol 2020; 24:421-448. [PMID: 32172396 DOI: 10.1007/s10151-020-02183-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/24/2020] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- G Pellino
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy.
| | - D S Keller
- Division of Colon and Rectal Surgery, Department of Surgery, New York-Presbyterian, Columbia University Medical Center, New York, NY, USA
| | | | - I Angriman
- General Surgery Unit, Azienda Ospedaliera di Padova, Padua, Italy
| | - M Carvello
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - V Celentano
- Portsmouth Hospitals NHS Trust, University of Portsmouth, Portsmouth, UK
| | - F Colombo
- L. Sacco University Hospital, Milan, Italy
| | - F Di Candido
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - S Laureti
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - G Luglio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - G Poggioli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - M Rottoli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - S Scaringi
- Surgical Unit, Department of Surgery and Translational Medicine, University of Firenze, Florence, Italy
| | - G Sciaudone
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
| | - G Sica
- Minimally Invasive and Gastro-Intestinal Unit, Department of Surgery, Policlinico Tor Vergata, Rome, Italy
| | - L Sofo
- Abdominal Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Rome, Rome, Italy
| | - S Leone
- CEO, Associazione nazionale per le Malattie Infiammatorie Croniche dell'Intestino "A.M.I.C.I. Onlus", Milan, Italy
| | - S Danese
- Division of Gastroenterology, IBD Center, Humanitas University, Rozzano, Milan, Italy
| | - A Spinelli
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - G Delaini
- Department of Surgery, "Pederzoli" Hospital, Peschiera del Garda, Verona, Italy
| | - F Selvaggi
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
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26
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Fahim M, Dijksman L, van Kessel C, Smeeing D, Braaksma A, Derksen W, Smits A. Promising results of a new treatment in patients with bowel obstruction in colorectal surgery. Eur J Surg Oncol 2020; 46:415-419. [DOI: 10.1016/j.ejso.2019.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 10/10/2019] [Indexed: 12/15/2022] Open
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Abdalla S, Brouquet A, Maggiori L, Zerbib P, Denost Q, Germain A, Cotte E, Beyer-Berjot L, Munoz-Bongrand N, Desfourneaux V, Rahili A, Duffas JP, Pautrat K, Denet C, Bridoux V, Meurette G, Faucheron JL, Loriau J, Guillon F, Vicaut E, Benoist S, Panis Y, Lefevre JH. Postoperative Morbidity After Iterative Ileocolonic Resection for Crohn's Disease: Should we be Worried? A Prospective Multicentric Cohort Study of the GETAID Chirurgie. J Crohns Colitis 2019; 13:1510-1517. [PMID: 31051502 DOI: 10.1093/ecco-jcc/jjz091] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS To compare perioperative characteristics and outcomes between primary ileocolonic resection [PICR] and iterative ileocolic resection [IICR] for Crohn's disease [CD]. METHODS From 2013 to 2015, 567 patients undergoing ileocolonic resection were prospectively included in 19 centres of the GETAID chirurgie group. Perioperative characteristics and postoperative results of both groups [431 PICR, 136 IICR] were compared. Uni- and multivariate analyses of the risk factors of overall 30-day postoperative morbidity was carried out in the IICR group. RESULTS IICR patients were less likely to be malnourished [27.2% vs 39.9%, p = 0.007], and had more stricturing forms [69.1% vs 54.3%, p = 0.002] and less perforating disease [19.9% vs 39.2%, p < 0.001]. Laparoscopy was less commonly used in IICR [45.6% vs 84.5%, p < 0.01] and was associated with increased conversion rates [27.4% vs 14.6%, p = 0.012]. Overall postoperative morbidity was 36.8% in the IICR group and 26.7% in the PICR group [p = 0.024]. There was no significant difference between IICR and PICR regarding septic intra-abdominal complications, anastomotic leakage [8.8% vs 8.4%] or temporary stoma requirement. IICR patients were more likely to present with non-infectious complications and ileus [11.8% vs 3.7%, p < 0.001]. Uni- and multivariate analyses did not identify specific risk factors of overall postoperative morbidity in the IICR group. CONCLUSIONS Surgery for recurrent CD is associated with a slight increase of non-infectious morbidity [postoperative ileus] that mainly reflects the technical difficulties of these procedures. However, IICR remains a safe therapeutic option in patients with recurrent CD because severe morbidity including anastomotic complications is similar to patients undergoing primary resection. PODCAST This article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast.
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Affiliation(s)
- Solafah Abdalla
- Sorbonne Université, Department of Digestive Surgery, AP-HP, Hôpital Saint Antoine, Paris, France; Saint-Antoine IBD Network
| | - Antoine Brouquet
- Service de Chirurgie Digestive, Hôpital Bicêtre, APHP, Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - Léon Maggiori
- Service de Chirurgie Colorectale, Hôpital Beaujon, APHP, Université Paris VII, Clichy, France
| | | | - Quentin Denost
- Service de Chirurgie Digestive, CHRU Bordeaux, Bordeaux, France
| | | | - Eddy Cotte
- Service de Chirurgie Digestive, CHRU Lyon-Sud, Pierre-Bénite, France
| | | | - Nicolas Munoz-Bongrand
- Service de Chirurgie Digestive, Hôpital Saint-Louis, APHP, Université Paris VII, Paris, France
| | | | - Amine Rahili
- Service de Chirurgie Digestive, CHRU Nice, Nice, France
| | - Jean-Pierre Duffas
- Service de Chirurgie Digestive, CHRU Toulouse-Rangueil, Toulouse, France
| | - Karine Pautrat
- Service de Chirurgie Digestive, Hôpital Lariboisière, APHP, Université Paris VII, Paris, France
| | - Christine Denet
- Service de Chirurgie Digestive, Institut Mutualiste Montsouris, Paris, France
| | | | | | | | - Jérome Loriau
- Service de Chirurgie Digestive, Hôpital Saint Joseph, Paris, France
| | - Françoise Guillon
- Service de Chirurgie Digestive, CHRU Montpellier, Montpellier, France
| | - Eric Vicaut
- Unité de recherche clinique, Hôpital Fernand Widal, APHP, Université Paris VII, Paris, France
| | - Stéphane Benoist
- Service de Chirurgie Digestive, Hôpital Bicêtre, APHP, Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - Yves Panis
- Service de Chirurgie Colorectale, Hôpital Beaujon, APHP, Université Paris VII, Clichy, France
| | - Jérémie H Lefevre
- Sorbonne Université, Department of Digestive Surgery, AP-HP, Hôpital Saint Antoine, Paris, France; Saint-Antoine IBD Network
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Celentano V, O'Leary DP, Caiazzo A, Flashman KG, Sagias F, Conti J, Senapati A, Khan J. Longer small bowel segments are resected in emergency surgery for ileocaecal Crohn's disease with a higher ileostomy and complication rate. Tech Coloproctol 2019; 23:1085-1091. [PMID: 31664551 PMCID: PMC6872825 DOI: 10.1007/s10151-019-02104-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 10/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Repeated intestinal resections may have disabling consequences in patients with Crohn's disease even in the absence of short bowel syndrome. Our aim was to evaluate the length of resected small bowel in patients undergoing elective and emergency surgery for ileocolic Crohn's disease. METHODS A prospective observational study was conducted on patients undergoing surgery for ileocolonic Crohn's disease in a single colorectal centre from May 2010 to April 2018. The following patients were included: (1) patients with first presentation of ileocaecal Crohn's disease undergoing elective surgery; (2) patients with ileocaecal Crohn's disease undergoing emergency surgery; (3) patients with recurrent Crohn's disease of the distal ileum undergoing elective surgery. The primary outcomes were length of resected small bowel and the ileostomy rate. Operating time, complications and readmissions within 30 days were the secondary outcomes. RESULTS One hundred and sixty-eight patients were included: 87 patients in the elective primary surgery group, 50 patients in the emergency surgery group and 31 in the elective redo surgery group. Eleven patients (22%) in the emergency surgery group had an ileostomy compared to 10 (11.5%) in the elective surgery group (p < 0.0001). In the emergency surgery group the median length of the resected small bowel was 10 cm longer than into the group having elective surgery for primary Crohn's disease. CONCLUSIONS Patients undergoing emergency surgery for Crohn's disease have a higher rate of stoma formation and 30-day complications. Laparoscopic surgery in the emergency setting has a higher conversion rate and involves resection of longer segments of small bowel.
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Affiliation(s)
- V Celentano
- Colorectal Unit, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK.
- University of Portsmouth, Portsmouth, UK.
| | - D P O'Leary
- Colorectal Unit, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - A Caiazzo
- University of Campania "Luigi Vanvitelli", Naples, Italy
| | - K G Flashman
- Colorectal Unit, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - F Sagias
- Colorectal Unit, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - J Conti
- Colorectal Unit, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - A Senapati
- Colorectal Unit, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - J Khan
- Colorectal Unit, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
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29
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Yu ZL, Lin DZ, Hu JC, Chen YF, Cai ZR, Zou YF, Ke J, Guo XF, Lan P, Wu XJ. Laparoscopic Surgery for Complex Crohn's Disease: A Meta-Analysis. J Laparoendosc Adv Surg Tech A 2019; 29:1397-1404. [PMID: 31414963 DOI: 10.1089/lap.2019.0398] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Zhao-liang Yu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - De-zheng Lin
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Ambulatory Surgery Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jian-cong Hu
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Ambulatory Surgery Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yu-feng Chen
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ze-rong Cai
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yi-feng Zou
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jia Ke
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xue-feng Guo
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Ambulatory Surgery Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ping Lan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiao-jian Wu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Abstract
Minimally invasive approaches are safe, feasible, and often recommended as the initial choice in the surgical management of Crohn's disease. However, a consensus has not been reached as the ideal approach in the surgical treatment of complex and recurrent Crohn's disease. Laparoscopy may provide advantages such as shorter length of stay and decreased postoperative pain and result in less adhesion formation in patients with complex disease. Robotic techniques may be beneficial in selected patients for completion proctectomy, providing better visualization in the narrow pelvis and increased dexterity. Decision of surgical technique should be made on a case-by-case basis.
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Affiliation(s)
- Ipek Sapci
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Bouquot M, Maggiori L, Hain E, Prost A la Denise J, Bouhnik Y, Panis Y. What is the outcome for patients undergoing more than two ileocolonic resections for recurrent Crohn's disease? A comparative study of 569 consecutive procedures. Colorectal Dis 2019; 21:563-569. [PMID: 30659742 DOI: 10.1111/codi.14562] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 12/31/2018] [Indexed: 12/23/2022]
Abstract
AIM To assess the outcome for patients undergoing repeated ileocolonic resection for recurrent Crohn's disease (CD). METHOD All patients undergoing ileocolonic resection for terminal ileal CD between 1998 and 2016 in our tertiary care centre were retrospectively reviewed. RESULTS Between 1998 and 2016, 569 ileocolonic resections were performed for CD: 403 of these were primary resections (1R, 71%), 107 second resections (2R, 19%) and 59 were third (or more) resections (> 2R, 10%). The laparoscopic approach rate was significantly less in the > 2R group (20/59, 34%) compared with the 2R (71/107, 66%; P = 0.002) and 1R (366/403, 91%) groups. However, conversion to an open approach did not show any difference between the three groups [1R group 46/366 (13%) vs 2R group 14/71 (20%) vs > 2R group 3/20 (15%); 1R vs > 2R P = 0.750; 2R vs > 2R P = 0.633]. Postoperative morbidity was significantly increased in the > 2R (28/59, 52%) group compared with the 1R group (115/403, 29%; P < 0.001) but showed no difference compared with the 2R group (43/107, 40%; P = 0.365). There was no difference between the groups in the incidence of severe postoperative morbidity (Clavien-Dindo ≥ 3) [1R group n = 24 (6%); 2R group n = 6 (6%); > 2R group n = 4, 7%; 1R vs > 2R P = 0.865, 2R vs > 2R P = 0.761]. CONCLUSION Although the overall morbidity rate was higher, repeated surgery for recurrent CD in patients undergoing three or more ileocolonic resections was not associated with an increased risk of severe postoperative morbidity in our series.
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Affiliation(s)
- M Bouquot
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP), University Denis Diderot (Paris VII), Clichy, France
| | - L Maggiori
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP), University Denis Diderot (Paris VII), Clichy, France
| | - E Hain
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP), University Denis Diderot (Paris VII), Clichy, France
| | - J Prost A la Denise
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP), University Denis Diderot (Paris VII), Clichy, France
| | - Y Bouhnik
- Department of Gastro-enterology, Inflammatory Bowel Disease and Nutritive Assistance, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP), University Denis Diderot (Paris VII), Clichy, France
| | - Y Panis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP), University Denis Diderot (Paris VII), Clichy, France
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Maeda K, Nagahara H, Shibutani M, Fukuoka T, Inoue T, Ohira M. A review of reports on single-incision laparoscopic surgery for Crohn's disease. Surg Today 2019; 49:361-368. [PMID: 30805721 DOI: 10.1007/s00595-018-1732-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/20/2018] [Indexed: 02/06/2023]
Abstract
The aim of this review was to analyze the currently available literature on single-incision laparoscopic surgery (SILS) for Crohn's disease (CD) with respect to surgical indications, surgical techniques, feasibility, and possible benefits of SILS for CD. A systematic query of articles published from January 2010 to July 2018 was performed. The studies were assessed for patient's age, gender, body mass index, disease type, SILS procedure, surgical procedure, incision length, operation time, rates of conversion to open surgery, postoperative complications, mortality, length of hospital stay, and rates of reoperation. After an initial review, 11 reports were selected. The surgical techniques and instruments showed wide variation. The mean operation time for SILS tended to be shorter than that for multiport laparoscopic surgery (MLS). The reported rates of conversion to open surgery and postoperative complications were not very different from those reported for MLS. In conclusion, the present review suggests that the SILS technique may be feasible and safe for select patients with CD. However, because we reviewed only a few studies with small sample sizes, prospectively designed trials with a large number of patients are required to clarify the true benefits of SILS for CD.
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Affiliation(s)
- Kiyoshi Maeda
- Department of Gastroenterological Surgery, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, 534-0021, Osaka, Japan. .,Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | - Hisashi Nagahara
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masatsune Shibutani
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tatsunari Fukuoka
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toru Inoue
- Department of Gastroenterological Surgery, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, 534-0021, Osaka, Japan
| | - Masaichi Ohira
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Anti-TNF Therapy Is Associated With an Increased Risk of Postoperative Morbidity After Surgery for Ileocolonic Crohn Disease: Results of a Prospective Nationwide Cohort. Ann Surg 2019; 267:221-228. [PMID: 29300710 DOI: 10.1097/sla.0000000000002017] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine the risk factors of morbidity after surgery for ileocolonic Crohn disease (CD). SUMMARY BACKGROUND DATA The risk factors of morbidity after surgery for CD, particularly the role of anti-TNF therapy, remain controversial and have not been evaluated in a large prospective cohort study. METHODS From 2013 to 2015, data on 592 consecutive patients who underwent surgery for CD in 19 French specialty centers were collected prospectively. Possible relationships between anti-TNF and postoperative overall morbidity were tested by univariate and multivariate analyses. Because treatment by anti-TNF is possibly dependent on the characteristics of the patients and disease, a propensity score was calculated and introduced in the analyses using adjustment of the inverse probability of treatment-weighted method. RESULTS Postoperative mortality, overall and intra-abdominal septic morbidity rates in the entire cohort were 0%, 29.7%, and 8.4%, respectively; 143 (24.1%) patients had received anti-TNF <3 months prior to surgery. In the multivariate analysis, anti-TNF <3 months prior to surgery was identified as an independent risk factor of the overall postoperative morbidity (odds-ratio [OR] =1.99; confidence interval [CI] 95% = 1.17-3.39, P = 0.011), with preoperative hemoglobin <10 g/dL (OR = 4.77; CI 95% = 1.32-17.35, P = 0.017), operative time >180 min (OR = 2.71; CI 95% = 1.54-4.78, P < 0.001) and recurrent CD (OR = 1.99; CI 95% = 1.13-3.36, P = 0.017). After calculating the propensity score and adjustment according to the inverse probability of treatment-weighted method, anti-TNF <3 months prior to surgery remained associated with a higher risk of overall (OR = 2.98; CI 95% = 2.04-4.35, P <0.0001) and intra-abdominal septic postoperative morbidities (OR = 2.22; CI 95% = 1.22-4.04, P = 0.009). CONCLUSIONS Preoperative anti-TNF therapy is associated with a higher risk of morbidity after surgery for ileocolonic CD. This information should be considered in the surgical management of these patients, particularly with regard to the preoperative preparation and indication of temporary defunctioning stoma.
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Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
AIM There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.
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Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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Luglio G, Cassese G, Amendola A, Rispo A, Maione F, De Palma GD. Novel Approaches to Ileocolic and Perianal Fistulising Crohn's Disease. Gastroenterol Res Pract 2018; 2018:3159543. [PMID: 30584421 PMCID: PMC6280273 DOI: 10.1155/2018/3159543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/12/2018] [Accepted: 10/17/2018] [Indexed: 12/18/2022] Open
Abstract
Crohn's disease (CD) is a well-known idiopathic inflammatory bowel disease characterised by transmural inflammation which can ordinarily affect all the gastrointestinal tract. Its true aetiology is unknown, and a causal therapy is not available to date. The most peculiar aspect of CD lies in its absolute heterogeneity, as we might face various scenarios, locations of the disease, pathologic behaviours, and severity of the disease itself. For these reasons, the cornerstone for the treatment of CD lies in a complex multimodal management, requiring close collaborations among surgeons, gastroenterologists, radiologists, and staff nurses. Advances in surgical and medical therapy are changing the course of the disease. Nowadays, the introduction of both laparoscopy and novel surgical techniques, the improvement of recovery pathways, and the opening of new frontiers are allowing healthcare professionals to deal with complex and recurrent scenarios, trying to spare bowel and anal function, thus ensuring a better quality of life for the patient. Given the heterogeneity and complexity of this disease, it would be impractical to encompass all the aspects of surgical management of CD. This review will address areas that are considered to be hot topics, controversies, challenges, and novelties: thus, we will focus on complex ileocecal disease, surgical strategies, and fistulising perianal conditions.
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Affiliation(s)
- Gaetano Luglio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Italy
| | - Gianluca Cassese
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Italy
| | - Alfonso Amendola
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Italy
| | - Antonio Rispo
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Italy
| | - Francesco Maione
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Italy
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Italy
- Center of Excellence for Technical Innovation in Surgery, Italy
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Preoperative evaluation of small bowel complications in Crohn’s disease: comparison of diffusion-weighted and contrast-enhanced MR imaging. Eur Radiol 2018; 29:2034-2044. [DOI: 10.1007/s00330-018-5734-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 08/12/2018] [Accepted: 08/28/2018] [Indexed: 02/08/2023]
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Aydinli HH, Aytac E, Remzi FH, Bernstein M, Grucela AL. Factors Associated with Short-Term Morbidity in Patients Undergoing Colon Resection for Crohn's Disease. J Gastrointest Surg 2018; 22:1434-1441. [PMID: 29663305 DOI: 10.1007/s11605-018-3763-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 03/24/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients undergoing colon resection for Crohn's disease are at risk of developing postoperative complications. The aim of this study is to identify factors associated with short-term (30-day) morbidity in patients undergoing colon resection for Crohn's disease from a national database. METHODS Patients who underwent colon resection for Crohn's disease in 2015 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The groups were classified based on presence of postoperative 30-day complications. The overall morbidity was calculated by including patients who had at least one postoperative complication. Demographics, preoperative, and operative factors were assessed and compared between the two groups. Further multivariate logistic regression analysis was conducted. RESULTS A total of 1643 patients met the inclusion criteria [mean age of 41.2 (± 15.5) years, 871 (53%) female]. Sixty percent (n = 993) of the procedures were performed laparoscopically and 128 (12.8%) cases were converted to open. Ninety-five patients (5%) underwent emergent resections. Thirty percent (n = 507) of patients had at least one postoperative complication within 30 days of surgery. Ileus (16%), transfusion (7%), and organ-space surgical site infection (6%) were the most common morbidities. Independent risk factors for postoperative morbidity were male gender (p = 0.01), open surgery (p = 0.002), preoperative severe anemia (p = 0.001), and preoperative weight loss (p = 0.04). CONCLUSION Approximately one third of the patients who undergo colon resection for Crohn's disease experience postoperative complications. Preoperative optimization of nutrition and anemia may improve outcomes. Laparoscopic technique appears to be the preferred surgical treatment option for resection when feasible.
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Affiliation(s)
- H Hande Aydinli
- Department of Surgery, Division of Colon and Rectal Surgery, Department of Colorectal Surgery, New York University Langone Medical Center, 530 First Ave Suite 7V, New York, NY, 10016, USA
| | - Erman Aytac
- Department of Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Feza H Remzi
- Department of Surgery, Division of Colon and Rectal Surgery, Department of Colorectal Surgery, New York University Langone Medical Center, 530 First Ave Suite 7V, New York, NY, 10016, USA
| | - Mitchell Bernstein
- Department of Surgery, Division of Colon and Rectal Surgery, Department of Colorectal Surgery, New York University Langone Medical Center, 530 First Ave Suite 7V, New York, NY, 10016, USA
| | - Alexis L Grucela
- Department of Surgery, Division of Colon and Rectal Surgery, Department of Colorectal Surgery, New York University Langone Medical Center, 530 First Ave Suite 7V, New York, NY, 10016, USA.
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Iesalnieks I, Hoene M, Bittermann T, Schlitt HJ, Hackl C. Mechanical Bowel Preparation (MBP) Prior to Elective Colorectal Resections in Crohn's Disease Patients. Inflamm Bowel Dis 2018. [PMID: 29529206 DOI: 10.1093/ibd/izx088] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Studies addressing the role of mechanical bowel preparation (MBP) in Crohn's disease (CD) patients are lacking. METHODS Consecutive elective colorectal resections for CD have been included in the present analysis. Exclusion criteria were small bowel resections not including colon, urgent surgeries, surgeries for cancer, and abdominoperineal resections for perianal disease. MBP was performed routinely between 1992 and 2004, omitted between 2005 and 2015, and reintroduced in 2016.Intraabdominal septic complications (IASC) were anastomotic leakage, intraabdominal abscess, intestinal fistula, and peritonitis. RESULTS Overall, 680 bowel resections for CD have been performed between 1992 and 2017. After exclusion of the abovementioned patients, 549 patients were included in the present analysis. The IASC rate was 12% in patients undergoing surgery after MPB as opposed to 24% when MBP was omitted (P < 0.001). By the multivariate analysis, preoperative MBP significantly reduced the risk of IASC (Hazard ratio 0.45; 95% CI, 0.23 - 0.86; P = 0.016). Preoperative weight loss (HR 2.0; 95% CI, 1.1 - 3.6; P = 0.024), penetrating disease (HR 2.6; 95% CI, 1.3 - 5.4; P = 0.01), and stapled as opposed to hand-sewn ileocolic anastomosis (HR 3.3; 95% CI, 1.4 - 7.7; P = 0.006) were associated with an increased risk of IASC. The positive impact of MBP was strongest on anastomotic complication rate in patients undergoing ileocolic resections for penetrating disease (11% vs 36%, P < 0.001). CONCLUSION Preoperative MPB should be strongly considered before colorectal surgery in patients with CD, especially in patients undergoing ileocolic resections for penetrating disease.
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Affiliation(s)
- Igors Iesalnieks
- Department of Surgery, University of Regensburg, Germany.,Department of Surgery, Marienhospital Gelsenkirchen, Germany
| | - Melanie Hoene
- Department of Surgery, University of Regensburg, Germany
| | | | - Hans J Schlitt
- Department of Surgery, University of Regensburg, Germany
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Laparoscopic resection for primary and recurrent Crohn's disease: A case series of over 100 consecutive cases. Int J Surg 2017; 47:69-76. [DOI: 10.1016/j.ijsu.2017.09.055] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 09/13/2017] [Accepted: 09/16/2017] [Indexed: 12/11/2022]
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Leo CA, Samaranayake SF, Chandrasinghe PC, Shaikh IA, Hodgkinson JD, Warusavitarne JH. Single Port Laparoscopic Surgery for Complex Crohn's Disease Is Safe with a Lower Conversion Rate. J Laparoendosc Adv Surg Tech A 2017; 27:1095-1100. [PMID: 28475480 DOI: 10.1089/lap.2016.0567] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Cosimo Alex Leo
- Department of Surgery, St. Mark's Hospital Academic Institute, London North West NHS Trust, Harrow, United Kingdom
- Imperial College of London, London, United Kingdom
| | - Sanjeev F. Samaranayake
- Department of Surgery, St. Mark's Hospital Academic Institute, London North West NHS Trust, Harrow, United Kingdom
| | - Pramodh C. Chandrasinghe
- Department of Surgery, St. Mark's Hospital Academic Institute, London North West NHS Trust, Harrow, United Kingdom
| | - Irshad A. Shaikh
- Department of Surgery, St. Mark's Hospital Academic Institute, London North West NHS Trust, Harrow, United Kingdom
| | - Jonathan D. Hodgkinson
- Department of Surgery, St. Mark's Hospital Academic Institute, London North West NHS Trust, Harrow, United Kingdom
- Imperial College of London, London, United Kingdom
| | - Janindra H. Warusavitarne
- Department of Surgery, St. Mark's Hospital Academic Institute, London North West NHS Trust, Harrow, United Kingdom
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Maeda K, Nagahara H, Shibutani M, Fukuoka T, Nakao S, Yamagami H, Kamata N, Muguruma K, Tanaka H, Toyokawa T, Hirakawa K, Ohira M. The feasibility and short-term clinical outcomes of single-incision laparoscopic surgery for patients with complex Crohn’s disease. Surg Today 2017; 48:242-247. [DOI: 10.1007/s00595-017-1581-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 07/31/2017] [Indexed: 01/21/2023]
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Mege D, Panís Y. Laparoscopic approach in Crohn's disease. Cir Esp 2017; 95:555-557. [PMID: 28602393 DOI: 10.1016/j.ciresp.2017.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 04/25/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Diane Mege
- Departamento de Cirugía Colorrectal, Pôle des Maladies de l'Appareil Digestif (PMAD), Hospital de Beaujon, Assistance Publique-Hôpitaux de Paris (AP-HP), Universidad Denis Diderot (París VII) , Clichy, Francia
| | - Yves Panís
- Departamento de Cirugía Colorrectal, Pôle des Maladies de l'Appareil Digestif (PMAD), Hospital de Beaujon, Assistance Publique-Hôpitaux de Paris (AP-HP), Universidad Denis Diderot (París VII) , Clichy, Francia.
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Sevim Y, Akyol C, Aytac E, Baca B, Bulut O, Remzi FH. Laparoscopic surgery for complex and recurrent Crohn’s disease. World J Gastrointest Endosc 2017; 9:149-152. [PMID: 28465780 PMCID: PMC5394720 DOI: 10.4253/wjge.v9.i4.149] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 01/03/2017] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
Crohn’s disease (CD) is a chronic inflammatory disease of digestive tract. Approximately 70% of patients with CD require surgical intervention within 10 years of their initial diagnosis, despite advanced medical treatment alternatives including biologics, immune suppressive drugs and steroids. Refractory to medical treatment in CD patients is the common indication for surgery. Unfortunately, surgery cannot cure the disease. Minimally invasive treatment modalities can be suitable for CD patients due to the benign nature of the disease especially at the time of index surgery. However, laparoscopic management in fistulizing or recurrent disease is controversial. Intractable fibrotic strictures with obstruction, fistulas with abscess formation and hemorrhage are the surgical indications of recurrent CD, which are also complicating laparoscopic treatments. Nevertheless, laparoscopy can be performed in selected CD patients with safety, and may provide better outcomes compared to open surgery. The common complication after laparoscopic intervention is postoperative ileus seems and this may strongly relate excessive manipulation of the bowel during dissection. But additionally, unsuccessful laparoscopic attempts requiring conversion to open surgery have been a major concern due to presumed risk of worse outcomes. However, recent data show that conversions do not to worsen the outcomes of colorectal surgery in experienced hands. In conclusion, laparoscopic treatment modalities in recurrent CD patients have promising outcomes when it is used selectively.
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Abstract
Laparoscopic surgery has revolutionized the delivery of care to the surgical patient undergoing colorectal resection. Since the first laparoscopic-assisted colectomy in 1991, significant advances have been made in minimally invasive colorectal surgery. For many benign conditions, laparoscopic colectomy has been proven to be safe and effective, and in some instances superior when compared with open surgery. Complex laparoscopic resections such as those for diverticulitis and inflammatory bowel disease have also been shown to have equivalent outcomes when compared with open surgery. Short-term benefits of a minimally invasive approach include less pain, decreased rates of wound infection and postoperative morbidity, faster return of bowel function, and shorter length of stay. Improvements in long-term complications have also been noted with lower incidence of incisional hernias and small bowel obstructions secondary to adhesions. As surgeons become more facile with laparoscopic resection, more complex cases such as those for complicated diverticulitis and reoperative surgery for inflammatory bowel disease can be completed with shorter operative times and decreased cost.
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Affiliation(s)
- Radhika Smith
- University of Chicago, Section of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
| | - David J. Maron
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, Florida
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Yamamoto-Furusho J, Bosques-Padilla F, de-Paula J, Galiano M, Ibañez P, Juliao F, Kotze P, Rocha J, Steinwurz F, Veitia G, Zaltman C. Diagnosis and treatment of inflammatory bowel disease: First Latin American Consensus of the Pan American Crohn's and Colitis Organisation. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2017. [DOI: 10.1016/j.rgmxen.2016.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Yamamoto-Furusho JK, Bosques-Padilla F, de-Paula J, Galiano MT, Ibañez P, Juliao F, Kotze PG, Rocha JL, Steinwurz F, Veitia G, Zaltman C. Diagnosis and treatment of inflammatory bowel disease: First Latin American Consensus of the Pan American Crohn's and Colitis Organisation. REVISTA DE GASTROENTEROLOGIA DE MEXICO 2017; 82:46-84. [PMID: 27979414 DOI: 10.1016/j.rgmx.2016.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 06/23/2016] [Accepted: 07/06/2016] [Indexed: 02/08/2023]
Abstract
The incidence and prevalence of inflammatory bowel disease (IBD) has increased in recent years in several Latin American countries. There is a need to raise awareness in gastroenterologists and the population in general, so that early diagnosis and treatment of ulcerative colitis (UC) and Crohn's Disease (CD) can be carried out. It is important for all physicians to have homogeneous criteria regarding the diagnosis and treatment of IBD in Latin America. The Pan American Crohn's and Colitis Organisation (PANCCO) is an organization that aims to include all the countries of the Americas, but it specifically concentrates on Latin America. The present Consensus was divided into two parts for publication: 1) Diagnosis and treatment and 2) Special situations. This is the first Latin American Consensus whose purpose is to promote a perspective adapted to our Latin American countries for the diagnosis, treatment, and monitoring of patients with UC and CD.
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Affiliation(s)
- J K Yamamoto-Furusho
- Clínica de Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.
| | - F Bosques-Padilla
- Gastroenterology Division, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México; Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, México
| | - J de-Paula
- Servicio de Gastroenterología, Hospital Italiano, Buenos Aires, Argentina
| | - M T Galiano
- Clínica de Enfermedad Inflamatoria Intestinal, Clínica Marly, Bogotá, Colombia
| | - P Ibañez
- Programa de Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
| | - F Juliao
- Clínica de Enfermedad Inflamatoria Intestinal, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - P G Kotze
- Hospital Universitario Cajuru, Universidad Católica del Paraná (PUCPR), Curitiba, Brasil
| | - J L Rocha
- Grupo Académico y de Investigación sobre Enfermedad de Crohn y Colitis Ulcerosa Crónica Idiopática de México, Ciudad de México, México
| | - F Steinwurz
- Hospital Israelita Albert Einstein, São Paulo, Brasil
| | - G Veitia
- Servicio de Gastroenterología, Hospital Vargas, Caracas, Venezuela
| | - C Zaltman
- Servicio de Gastroenterología, Hospital Clementino Fraga Filho, Departamento de Medicina Interna, Universidade Federal do Rio de Janeiro (UFRJ), Río de Janeiro, Brasil
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Beaupel N, Brouquet A, Abdalla S, Carbonnel F, Penna C, Benoist S. Preoperative oral polymeric diet enriched with transforming growth factor-beta 2 (Modulen) could decrease postoperative morbidity after surgery for complicated ileocolonic Crohn's disease. Scand J Gastroenterol 2017; 52:5-10. [PMID: 27553420 DOI: 10.1080/00365521.2016.1221994] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Exclusive polymeric diet enriched with transforming growth factor-beta 2 (ANS-TGF-β2) has been used for remission induction and maintenance in pediatric Crohn's disease (CD). Its use in the preoperative setting has never been evaluated. The aim of this study was to evaluate preoperative ANS-TGF-β2 to decrease postoperative complications after surgery for complicated ileocolonic CD. METHODS From 2011 to 2015, data of all consecutive patients who underwent elective surgery for ileocolonic CD were collected prospectively. Preoperative, exclusive ANS-TGF-β2 was administered in high-risk patients with complicated CD. Complicated CD was defined by the presence of obstructive symptoms, and/or steroid treatment, and/or preoperative weight loss >10% and/or perforating CD. Outcomes of high-risk patients receiving preoperative ANS-TGF-β2 were compared to those of low-risk patients with no complicated CD who underwent upfront surgery. RESULTS Fifty-six patients underwent surgery for ileocolonic CD. Among them, 35 high-risk patients received preoperative ANS-TGF-β2 and 21 low-risk patients underwent upfront surgery. Preoperative full-dose ANS-TGF-β2 was feasible in 34/35 high-risk patients. Discontinuation of steroids during preoperative ANS-TGF-β2 could be achieved in 10/16 patients (62.5%). Postoperative complications rates were 8/35 (23.8%) and 5/21 (22.9%) in high-risk and low-risk patients, respectively (p = 1). Temporary ileocolostomy rates in high-risk patients and in low-risk patients were 4/35 (11%) and 0/21, respectively (p = 0.286) Conclusion: Preoperative ANS-TGF-β2 is feasible in most high-risk patients with complicated ileocolonic CD and could limit the deleterious effects of risk factors of postoperative morbidity. These results need to be confirmed in a large randomized controlled trial.
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Affiliation(s)
- Nathan Beaupel
- a Department of Digestive and Oncologic Surgery, Assistance Publique Hôpitaux de Paris , Université Paris-Sud , Le Kremlin Bicêtre , France
| | - Antoine Brouquet
- a Department of Digestive and Oncologic Surgery, Assistance Publique Hôpitaux de Paris , Université Paris-Sud , Le Kremlin Bicêtre , France
| | - Solafah Abdalla
- a Department of Digestive and Oncologic Surgery, Assistance Publique Hôpitaux de Paris , Université Paris-Sud , Le Kremlin Bicêtre , France
| | - Franck Carbonnel
- b Department of Gastroenterology, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris , Université Paris-Sud , Le Kremlin Bicêtre , France
| | - Christophe Penna
- a Department of Digestive and Oncologic Surgery, Assistance Publique Hôpitaux de Paris , Université Paris-Sud , Le Kremlin Bicêtre , France
| | - Stéphane Benoist
- a Department of Digestive and Oncologic Surgery, Assistance Publique Hôpitaux de Paris , Université Paris-Sud , Le Kremlin Bicêtre , France
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Abstract
The majority of patients with Crohn's disease require abdominal surgery during their lifetime, some of whom will require multiple operations. Postoperative complications are seen more frequently in patients requiring abdominal surgery for Crohn's disease than in patients requiring abdominal surgery for other conditions. In this article, we review the evidence supporting preoperative optimization, discussing strategies that potentially improve surgical outcomes and reduce perioperative morbidity and mortality. We discuss the roles of adequate cross-sectional imaging, nutritional optimization, appropriate adjustments of medical therapy, management of preoperative abscesses and phlegmons, smoking cessation and thromboembolic prophylaxis. We also review operation-related factors, and discuss their potential implications with respect to postoperative complications. Overall, the literature suggests that preoperative management has a major effect on postoperative outcomes.
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Enriquez-Navascués JM, Elorza G, Placer C, Timoteo A, Velaz L, Borda N, Saralegui Y. Rehabilitación multimodal y cirugía intestinal por enfermedad de Crohn: Factores asociados a estancia hospitalaria prolongada. Cir Esp 2016; 94:531-536. [DOI: 10.1016/j.ciresp.2016.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 09/01/2016] [Accepted: 09/11/2016] [Indexed: 12/23/2022]
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Manabe T, Ueki T, Nagayoshi K, Moriyama T, Yanai K, Nagai S, Esaki M, Nakamura K, Nakamura M. Feasibility of laparoscopic surgery for complex Crohn's disease of the small intestine. Asian J Endosc Surg 2016; 9:265-269. [PMID: 27121153 DOI: 10.1111/ases.12287] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 02/16/2016] [Accepted: 02/29/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND The laparoscopic approach for complex Crohn's disease (CD), which involves abscess formation, fistula formation, and recurrent CD, is controversial. The aim of this study was to investigate the feasibility and safety of the laparoscopic approach for complex CD. METHODS Fifty-six patients who had undergone surgery for CD of the small bowel from January 2007 to August 2014 were divided into two groups: the laparoscopic approach for complex CD group (LC group, n = 31) and the laparoscopic approach for simple CD group (LS group, n = 25). The preoperative data and surgical outcomes of the LC group were compared with those of the LS groups. RESULTS There were no significant differences in preoperative data and operating time between the two groups. Blood loss was not significantly different between the LC and LS groups. The incision length was longer in the LC group than the LS group (P = 0.004). The incidence of severe postoperative complications in the LC group was higher than in the LS group (P = 0.026). The length of postoperative stay was similar in the LC and LS groups. CONCLUSIONS The laparoscopic approach for complex CD is feasible and provides good cosmesis that is comparable to that offered by simple CD.
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Affiliation(s)
- Tatsuya Manabe
- Department of Surgery and Oncology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan.
| | - Takashi Ueki
- Department of Surgery and Oncology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Kinuko Nagayoshi
- Department of Surgery and Oncology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Taiki Moriyama
- Department of Surgery and Oncology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Kosuke Yanai
- Department of Surgery and Oncology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Shuntaro Nagai
- Department of Surgery and Oncology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Motohiro Esaki
- Department of Medicine and Clinical Science, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Kazuhiko Nakamura
- Department of Medicine and Bioregulatory Science, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
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