The KONO-S (antimesenteric functional end-to-end handsewn) anastomosis has been used for Crohn's disease (CD) recently, with its efficacy in reducing the risk of anastomotic surgical recurrence. However, the anastomotic leakage is also found in CD with this technique. This study aims to evaluate the safety and feasibility of the KONO-S anastomosis with biodegradable stent in CD.

We performed a study of 56 CD patients undergoing bowel resection by the KONO-S anastomosis technique with or without biodegradable stent. Postoperative complications, time to first flatus, time to first defecation, and healing of the anastomosis were recorded, especially in patients receiving biodegradable stent.

The study included 24 CD patients receiving KONO-S anastomosis with biodegradable stent and 32 patients receiving normal KONO-S anastomosis. In patients with biodegradable stent, 8 patients received small bowel resection, 15 received ileocecal resection, and 1 received colectomy; the mean time for the new anastomosis technique was 15.8 ± 2.0 min. No stent-related complications were observed postoperatively. The time to first flatus and defecation was 2.3 ± 0.5 days and 3.7 ± 0.8 days in patients with biodegradable stent, respectively. All the stents degraded at almost 4-5 weeks after surgery. The colonoscopy showed that the healing condition of the anastomosis was good without any recurrence during 6-month follow-up in the stent group.

This is a pilot study that showed that the KONO-S anastomosis technique with biodegradable stent was safe and feasible in CD with lower risk of anastomotic complications and no serious adverse events.

Crohn's disease (CD) is a chronic immune-mediated disorder affecting the gastrointestinal tract. While medical therapies have advanced, approximately 80% of CD patients will require surgery due to disease recurrence. A significant debate exists regarding the primary site of post-operative recurrence. This discrepancy in recurrence patterns underscores the complexity of CD management and the ongoing need for tailored surgical approaches. It has been recently demonstrated that the Kono-S anastomosis is safe and efficient in reducing endoscopic and surgical recurrence. Newer versions of the Kono-S anastomosis using staplers have been reported to further simplify the procedure and decrease operative time. The aim of this paper was to describe a distinct version of a totally stapled Kono-S anastomosis and provide preliminary results from our center. The technical procedure of a totally stapled Kono-S anastomosis is illustrated. A consecutive series of patients undergoing ileal or ileo-colic resection followed by totally stapled Kono-S anastomosis was identified from a prospectively collated database. Data included patient demographics and baseline characteristics, intraoperative details, short- and long-term post-operative outcomes. Between January and November 2023, 41 patients (mean age 36.4 years, 61% males) underwent ileal or ileo-colic resection followed by totally stapled Kono-S anastomosis for Crohn's disease. Mean operative time was 150.76 ± 43.22 min, and mean time of anastomotic construction was 19.71 ± 4.24. Time to flatus and stool were 2.73 ± 0.70 and 3.51 ± 1.16 days, respectively, and the length of post-operative stay was 6.80 ± 2.13 days. Only two patients (4.8%) presented complications following surgery, namely anastomotic bleeding. At a mean follow-up of 17.0 ± 2.1 months, no patient needed re-do surgery for disease recurrence at anastomotic site. The endoscopic recurrence rate was 14.4% (4/28). Our fully stapled version of the Kono-S anastomosis is safe and feasible, and short construction time and low technical complexity may help its diffusion among colorectal surgeons. Long-term outcomes on disease recurrence are still to be defined.

Inflammatory bowel disease (IBD) encompasses a spectrum of chronic, idiopathic, and progressive inflammatory conditions of the gastrointestinal tract, with Crohn's disease and ulcerative colitis comprising the majority. Both conditions have distinct pathophysiological and clinical characteristics but share common immune-mediated mechanisms. Specific facets of IBD and its management in the pediatric population differ from adult parallels. This article explores the surgical treatments of pediatric IBD, focusing on indications for surgery and perioperative considerations.

The majority of patients with Crohn's disease, despite an ever-increasing number of advanced therapies, require abdominal surgery during their lifetime. In this review article, the authors provide a comprehensive overview of abdominal surgery for Crohn's disease, with an evidence-based focus on surgery for upper gastrointestinal Crohn's disease, bowel-preserving surgery with strictureplasties, selection of ileocolic anastomotic technique for terminal ileal Crohn's disease, extended resections and proctectomy for Crohn's proctocolitis, intentional ileoanal pouch for Crohn's disease, and several "hot topics" including early surgery for ileocolic Crohn's disease, and surgical approaches that target the mesentery including the Kono-S anastomosis and extended mesenteric excision.

Recurrence after surgically induced remission in Crohn's disease remains a topic of research and debate with significant clinical implications for overall quality of life and intestinal and defecatory functions. While the surgeon continues to play a critical role in surgical prophylaxis of recurrence, optimal results will only be obtained in the setting of a true multidisciplinary team approach, following the principles of "the right surgery, on the right patient, at the right time, performed by the right surgeon, supported by the right team." The centerpiece of surgical prophylaxis is the intestinal anastomosis. The ideal anastomosis after resection for Crohn's disease should be safe and reliable, as postoperative septic complications have been shown to increase the risk of recurrence; result in a wide lumen and a configuration that would not impede enteric flow; exclude or excise the mesentery, a known culprit in primary and recurrent disease; and preserve vascularization and innervation. This article will review the evidence supporting the above-mentioned surgical principles and the long-term results of the different anastomotic configurations.

Handsewn Kono-S anastomosis is safe and associated with a reduction in postoperative recurrence (POR) in Crohn disease (CD). This study aimed to investigate the advantages of stapled Kono-S anastomosis in patients with CD who underwent intestinal anastomosis.

Patients with CD who underwent intestinal anastomosis were reviewed via a prospectively maintained database. Patients who underwent conventional stapled side-to-side anastomosis were classified into the conventional group, and those who underwent stapled Kono-S anastomosis were classified into the Kono-S group. The primary endpoint was modified endoscopic recurrence (mER; ≥i2b). Other endpoints were endoscopic recurrence (ER; ≥i2); severe ER (i3 and i4); intra- and postoperative outcomes, including morbidity and hospital stay; and cross-sectional parameters. Multivariate logistic regression analysis was performed to assess the independent risk factors for mER.

Between 2020 and 2023, 199 patients (63 in the Kono-S group) were included in this study. After matching the 63 patients in each group, the overall rates of mER, ER, and severe ER were 19.0%, 24.6%, and 8.7%, respectively. The mER, ER, and severe ER rates were lower in the Kono-S group than in the conventional group (12.7% vs 25.4% [P =.07], 20.6% vs 28.6% [P =.30], and 6.3% vs 11.1% [P =.34], respectively). Multivariate analysis indicated that stapled Kono-S anastomosis (odds ratio [OR], 0.35; 95% CI, 0.12-0.98; P =.047) was an independent protective factor for mER, whereas male gender (OR, 7.75; 95% CI, 1.50-40.00; P =.01) and BMI of <18.5 kg/m2 (OR, 3.27; 95% CI, 1.11-9.67; P =.03) were independent risk factors for mER.

Stapled Kono-S anastomosis is safe for patients with CD. However, stapled Kono-S anastomosis may not be a protective factor against POR compared with conventional stapled side-to-side anastomosis.

Increasing evidence suggests that Crohn's disease is a primary mesenteropathy and that resection of the mesentery, or its exclusion from an anastomosis, may alter disease progression. If borne out in clinical trials, this observation would be welcome, as current pharmacotherapeutic approaches to Crohn's disease appear to have limited effect on disease progression. This article explores arguments for and against the alteration of mesenteric inputs by surgical means, in Crohn's disease.

Many patients with Crohn's disease (CD) will ultimately require surgical intervention for refractory disease despite recognizing that surgery does not cure CD. The initial operation, primarily for ileocolic disease, is focused on resecting the offending pathology and ideally providing a reduced likelihood for subsequent operations and additional bowel loss through surgical techniques. The appropriate margin, macro- vs. microscopic, lays in balance to provide an adequate resection that minimizes bowel loss, compared to an extensive resection which ensures a thorough resection but inherently includes the loss of normal bowel in attempts to reduce recurrent symptomatic disease. Ensuring the appropriately timed operation, performed in optimal conditions, with apt mesenteric resections and an ideal anastomotic configuration are all only part of the equation, as bowel margins play an important role in limiting surgical recurrence and maintaining bowel length. A grossly normal margin assessed by the lack of serositis and the mesenteric "pinch test" can result in an appropriate margin without sacrificing normal bowel in this group of patients who are at risk of further bowel loss from CD recurrence.

Crohn's disease (CD) negatively impacts quality of life, and a high percentage of patients will need surgery. Ileocecal resection (ICR) is the most common abdominal procedure performed in CD. Postoperative complications are frequent, and recurrence is common. The main objectives of this study were to analyze risk factors (RF) for anastomotic leakage (AL) and recurrence after ICR, as well as quality of life (QoL) in CD in a sample of the Spanish population.

A prospective, multicenter, observational study was designed, including all types of hospitals in Spain from 2018 to 2021. Demographic and medical-surgical characteristics, postoperative complications, hospital types by annual ICR volume, and quality of life (IBDQ-9) up to 1 year follow-up (OYF) were recorded and analyzed.

A total of 386 ICRs were recorded. At 60 days, there were 134 (36.4%) complications, 46 (11.91%) of which were major. A total of 23 (5.9%) AL were registered, and RF were Montreal A3 [OR 14.2, 95% CI (2.70-126), p = 0.005], Montreal p [OR 7.29, 95% CI (1.14-44.4), p = 0.029], and intensified adalimumab treatment [3.8, 95% CI (1.2-13.1), p = 0.026]. Recurrences at OYF were 67 (19%), and RF were history of neoplasia [OR 7.14, p = 0.01], Montreal B3 [OR 2.12, p = 0.02], and minimally invasive surgery (MIS) [OR 2.63, p = 0.02]. The mean difference in IBDQ-9 from baseline to 60 days was +1.72 (n = 177, p < 0.001) and to OYF +2.12 (n = 140, p < 0.001).

The AL rate was 5.9%. Montreal A3, perianal disease, and intensified adalimumab were associated with a higher rate of AL. The recurrence rate was 17.6% (OYF). Prior neoplasia, Montreal B3, and MIS were associated with higher risk of recurrence. ICR improves quality of life at 60 days and is maintained 1 year after surgery.

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

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

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

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

The Kono-S (KS) anastomosis for Crohn's disease (CD) is associated with improved endoscopic and clinical long-term outcomes. Ileocolonic anastomoses in CD are associated with an unacceptable anastomotic complication rate - up to 40%. Investigation of short-term benefits of KS is thus warranted. Here, we evaluate 90-d postoperative complications following KS versus side-to-side stapled anastomosis in patients with CD.

This is a retrospective case-control conducted at our tertiary medical center; data retrieved are from cases between January 2019 and May 2023. Thirty-eight consecutive patients with CD who underwent KS were matched with 38 patients who underwent side-to-side stapled anastomosis. Patients were initially age and sex matched; then, characteristics including body mass index, American Society of Anesthesiologists class, and disease severity indicated by inpatient status, preoperative laboratory values, steroid and disease modifying drug use were compared between cases and controls, using chi square, t-test, or Mann-Whitney U test.

Cohorts did not differ in the aforementioned characteristics with the exception of higher preoperative erythrocyte sedimentation rate in the KS group. There was no difference in operative approach, or complications between groups; one patient undergoing KS required return to operating room for fascial dehiscence, while two in the side-to-side stapled group required return to operating room for anastomotic complications. KS operative times were significantly longer.

KS is associated with an acceptable rate of short-term complications. In our matched series of 38 patients, we had no anastomotic leaks or bleeds in our KS group. Adoption of this technique may provide immediate postoperative benefits in addition to long-term disease reduction.

This article is the second in a series of two publications on the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of prior ECCO Guidelines.

Patients with Crohn's disease (CD) after ileocolic resection may develop an endoscopic postoperative recurrence (ePOR) that reaches 40% to 70% of incidence within 6 months. Recently, there has been growing interest in the potential effect of anastomotic configurations on ePOR. Kono-S anastomosis has been proposed for reducing the risk of clinical and ePOR. Most studies have assessed the association of ileocolonic anastomosis and ePOR individually, while there is currently limited data simultaneously comparing several types of anastomosis. Therefore, we performed a systematic review and meta-analysis to assess the impact of different ileocolonic anastomosis on ePOR in CD.

We searched PubMed and Embase from inception to January 2023 for eligible studies reporting the types of anastomoses and, based on these, the rate of endoscopic recurrence at ≥6 months. Studies were grouped by conventional anastomosis, including side-to-side, end-to-end, and end-to-side vs Kono-S, and comparisons were made between these groups. Pooled incidence rates of ePOR were computed using random-effect modelling.

Seventeen studies, with 2087 patients who underwent ileocolic resection for CD were included. Among these patients, 369 (17,7%) Kono-S anastomoses were performed, while 1690 (81,0%) were conventional ileocolic anastomosis. Endoscopic postoperative recurrence at ≥6 months showed a pooled incidence of 37.2% (95% CI, 27.7-47.2) with significant heterogeneity among the studies (P < .0001). In detail, patients receiving a Kono-S anastomosis had a pooled incidence of ePOR of 24.7% (95% CI, 6.8%-49.4%), while patients receiving a conventional anastomosis had an ePOR of 42.6% (95% CI, 32.2%-53.4%).

Kono-S ileocolic anastomosis was more likely to decrease the risk of ePOR at ≥6 months compared with conventional anastomosis. Our findings highlight the need to implement the use of Kono-S anastomosis, particularly for difficult to treat patients. However, results from larger randomized controlled trials are needed to confirm these data.

Surgical resection rates remain high in Crohn's disease (CD). Reducing postoperative recurrence (POR) is challenging. Besides drug therapy, the surgical anastomosis technique may reduce POR. We aimed to compare the endoscopic POR rate after Kono-S vs standard ileocolic anastomosis.

The study included all consecutive CD patients operated on for ileocolic resection with a Kono-S anastomosis between February 2020 and March 2022. These patients were prospectively followed, and colonoscopy was performed 6 to 12 months after surgery. Patients were compared with a historical cohort of patients operated on with a conventional anastomosis in the same center. The primary end point was endoscopic POR (Rutgeerts score ≥i2). Factors associated with POR were assessed by univariate and multivariable analyses.

A total of 85 patients were included, 30 in the Kono-S group and 55 in the control group. At baseline, there was no significant difference between the 2 groups regarding CD characteristics or known POR risk factors, including previous exposure to biologics. At 6 to 12 months, endoscopic POR rate did not differ significantly between groups (56.7% in the Kono-S group vs 49.1% in the control group; P = .50), nor did endoscopic POR according to the modified Rutgeerts score ≥i2b (46.7% in the Kono-S group vs 40% in the control group; P = .55). Severe endoscopic POR rates were 23.3% and 18.2% in each group, respectively. Clinical recurrence rate was similar in both groups, and no recurrent surgery occurred. By multivariable analysis, the type of anastomosis was not associated with endoscopic POR (OR, 1.229; 95% CI, 0.461-3.274, P = .68); however, postoperative treatment with anti-TNF was (OR, 0.337; 95% CI, 0.131-0.865 P = .02).

Kono-S anastomosis was not associated with a reduced rate of endoscopic POR. These results warrant confirmation in prospective, randomized, multicenter studies.

Kono-S anastomosis has gained increasing interest although evaluation of its impact on reducing Crohn's recurrence shows conflicting results. This study aimed to evaluate the short- and long-term outcomes for patients with Crohn's disease requiring surgery with Kono-S compared to conventional anastomosis.

A systematic review and meta-analysis included patients with Crohn's disease treated with bowel resection and Kono-S anastomosis reconstruction versus a comparator arm of conventional anastomosis technique. Recurrence outcomes examined were endoscopic recurrence rates, mean postoperative Rutgeerts score, surgical recurrence, clinical recurrence, and postoperative biologics use. Short-term postoperative outcomes include anastomotic leaks, surgical site infection, postoperative ileus, and mean operative time.

A total of 873 studies were identified with 15 remaining after abstract review encompassing 1501 patients, 765 with Kono-S and 736 with conventional anastomosis. Recurrence was significantly lower in the Kono-S arm, with endoscopic recurrence rates of 41% vs 48% (RR 0.86, 95% CI 0.73-1.00, p = 0.05) and surgical recurrence rates of 2.7% vs 21.0% (RR 0.13, 95% CI 0.06-0.30, p < 0.001). There was a significantly lower anastomotic leak rate in the Kono-S arm when compared to conventional anastomosis, 1.7% vs 4.9% (RR 0.37, 95% CI 0.19-0.74, p = 0.005). Mean operative time was similar between both groups.

Kono-S is a safe and feasible anastomotic technique with lower rates of endoscopic and surgical postoperative recurrence. While we await further trials to substantiate this benefit, Kono-S anastomosis should be considered as an important tool in the armamentarium of a surgeon in anastomotic construction to reduce recurrence.

Medical treatment for Crohn's disease (CD) has continuously improved, which has led to a decrease in surgical recurrence rates. Despite these advancements, 25% of patients will undergo repeat intestinal surgery. Recurrence of CD commonly occurs on the mesentery side of the anastomosis site.

To compare the new anti-mesenteric side-to-side delta-shaped stapled anastomosis (DSA) with the conventional stapled functional end-to-end anastomosis (CSA).

This retrospective study included CD patients who underwent ileo-ileal or ileo-colic anastomosis between January 2020 and December 2023. The DSA technique employed a stapler to maintain the concept of anti-mesentery side-to-side anastomosis by performing a 90° vertical closure of the open window compared with the CSA technique. At the corner where the open window is closed, the DSA avoids forming a pouch and creates an anastomosis resembling a delta shape within the intestinal lumen. We compared demographics, preoperative condition, operative findings, and operative outcomes for the two techniques.

The study included 175 patients, including 92 in the DSA group and 83 in the CSA group. The two groups were similar in baseline characteristics, preoperative medical treatment, and operative findings except for the Montreal classification location. The 30-days postoperative complication rate was significantly lower in the DSA group compared with the CSA group (16.3% vs 32.5%, P = 0.009). Ileus incidence was significantly lower in the DSA group than in the CSA group (4.3% vs 14.5%, P = 0.033), and the hospital stay was shorter in the DSA group than in the CSA group (5.67 ± 1.53 days vs 7.39 ± 3.68 days, P = 0.001).

The DSA technique was feasible and showed comparable postoperative outcomes with lower short-term complications compared with the CSA technique. Further studies on CD recurrence and long-term complications are warranted.

Kono-S anastomosis, an antimesenteric, functional, end-to-end handsewn anastomosis, was introduced in 2011. The aim of this meta-analysis is to evaluate the safety and effectivity of the Kono-S technique.

A comprehensive search of MEDLINE (PubMed), Embase (Elsevier), Scopus (Elsevier), and Cochrane Central (Ovid) from inception to August 24th, 2023, was conducted. Studies reporting outcomes of adults with Crohn's disease undergoing ileocolic resection with subsequent Kono-S anastomosis were included. PRISMA and Cochrane guidelines were used to screen, extract and synthesize data. Primary outcomes assessed were endoscopic, surgical and clinical recurrence rates, as well as complication rates. Data were pooled using random-effects models, and heterogeneity was assessed with I² statistics. ROBINS-I and ROB2 tools were used for quality assessment.

12 studies involving 820 patients met the eligibility criteria. A pooled mean follow-up time of 22.8 months (95% CI: 15.8, 29.9; I2 = 99.8%) was completed in 98.3% of patients. Pooled endoscopic recurrence was reported in 24.1% of patients (95% CI: 9.4, 49.3; I2 = 93.43%), pooled surgical recurrence in 3.9% of patients (95% CI: 2.2, 6.9; I2 = 25.97%), and pooled clinical recurrence in 26.8% of patients (95% CI: 14, 45.1; I2 = 84.87%). The pooled complication rate was 33.7%. The most common complications were infection (11.5%) and ileus (10.9%). Pooled anastomosis leakage rate was 2.9%.

Despite limited and heterogenous data, patients undergoing Kono-S anastomosis had low rates of surgical recurrence and anastomotic leakage with moderate rates of endoscopic recurrence, clinical recurrence and complications rate.

Crohn's disease has debilitating effects on patients' quality of life. Currently, there are limited data on the effect of anastomotic configuration on health-related quality of life after ileocaecal resection for Crohn's disease. This study aimed to assess the impact of Kono-S anastomosis on quality of life after ileocolic resection, compared to the conventional side-to-side anastomosis.

Patients with primary or recurrent Crohn's disease participating in the ongoing SuPREMe-CD trial were interviewed about quality of life using the Inflammatory Bowel Disease Questionnaire (IBDQ). The primary endpoint was disease-specific quality of life, assessed with IBDQ. Secondary outcomes were quality of life related to bowel symptoms, systemic symptoms, social function and emotional function.

Of the 94 patients included, 51 (54%) received the conventional side-to-side anastomosis and 43 (46%) the Kono-S anastomosis. Demographics were comparable between the two groups. The IBDQ was assessed at a mean follow-up of 54.0 ± 18.7 months from surgical intervention. The mean total IBDQ score was 155.1 ± 28.07 in the conventional group and 163.8 ± 25.23 in the Kono-S group (P = 0.11). When considering bowel symptoms and social function, mean scores were 50.7 and 23.5 in the conventional group, and 56.3 and 26.5 in the Kono-S group (P = 0.002 and P = 0.02, respectively). Kono-S anastomosis was independently associated with improved quality of life regarding bowel symptoms (P = 0.006) and social function (P = 0.03) after correcting for other confounding factors on linear regression analysis.

Compared to conventional side-to-side anastomosis, patients with Kono-S anastomosis presented significantly better bowel symptoms and social function scores at 54 months after surgery.

Postoperative anastomotic recurrence of Crohn's disease is challenging and can lead to symptom recurrence and further surgery. The mesenteric pole of the intestine is the initial site of macroscopic anastomotic recurrence, and the mesentery may play an important role in recurrence after surgical resection. Therefore, "mesenteric-based surgery" has gained increasing attention by clinicians. However, the role of mesentery in the postoperative recurrence remains controversial. This review will examine mesenteric changes in Crohn's disease, proposed roles for mesentery in disease progression, and the potential for mesenteric-based surgery in the surgical management of Crohn disease.

Crohn's disease is a complex condition that confers a significant risk of requiring multiple surgeries. Questions that surgeons must frequently answer include: which patients benefit from diversion? Does monoclonal antibody therapy increase post-operative complications? And, are there surgical techniques that can prevent the recurrence of Crohn's disease? This review examines current data to answer these questions.

Treatment of ulcerative colitis (UC) and Crohn's disease (CD) represents, in the majority of cases, a real challenge to the gastroenterologist's abilities and skills as well as a clinical test concerning his/her levels of medical knowledge and experience. During the last two decades, our pharmaceutical arsenal was significantly strengthened, especially after the introduction of the so-called biological agents, drugs which to a large extent not only improved the results of conservative treatment but also changed the natural history of the disease. However, colectomy is still necessary for some patients with severe UC although smaller compared to the past, precisely because of the improvements achieved in the available conservative treatment. Nevertheless, surgeries to treat colon dysplasia and cancer are increasing to some extent. At the same time, satisfactory improvements in surgical techniques, the pre-and post-operative care of patients, as well as the selection of the appropriate time for performing the surgery have been noticed. Regarding patients with CD, the improvement of conservative treatment did not significantly change the need for surgical treatment since two-thirds of patients need to undergo surgery at some point in the course of their disease. On the other hand, the outcome of the operation has improved through good preoperative care as well as the wide application of more conservative surgical techniques aimed at keeping as much of the bowel in situ as possible. This article discusses the indications for surgical management of UC patients from the gastroenterologist's point of view, the results of the emerging new techniques such as transanal surgery and robotics, as well as alternative operations to the classic ileo-anal-pouch anastomosis. The author also discusses the basic principles of surgical management of patients with CD based on the results of the relevant literature. The self-evident is emphasized, that is, to achieve an excellent therapeutic result in patients with severe inflammatory bowel disease in today's era; the close cooperation of gastroenterologists with surgeons, pathologists, imaging, and nutritionists is of paramount importance.

Crohn's disease is a relapsing inflammatory condition and disease recurrence after surgery is common. Significant variation in clinical practice remains despite progress in management of postoperative Crohn's disease. In this review, we summarise current management strategies and guidelines, unmet needs, and research progress in this field.

There has been real progress in risk stratifying individuals' postsurgery and tailoring therapies based on their risk; this has been incorporated into current management guidelines in the USA, UK, and Europe. Furthermore, novel noninvasive monitoring tools such as intestinal ultrasound have shown high sensitivity and specificity at detecting disease recurrence and are an attractive point-of-care test. Recent studies are also investigating multiomic biomarkers to prognosticate postoperative Crohn's disease. However, given the heterogeneity within this condition, large multicentre clinical validation across all age groups is needed for clinical translation in the future.

Ongoing progress in research and the development of novel prognostic and noninvasive disease monitoring tools offers hope for personalised therapy tailored to individual recurrence risk in postoperative Crohn's disease.

Crohn's disease (CD) is a chronic inflammatory disease of the gastrointestinal tract, often requiring intestinal resection as a common treatment. However, recurrence after surgery is common. The anastomotic configuration after bowel resection appears to be associated with the recurrence of CD. Previous studies have suggested that the Kono-S anastomosis may help to reduce the recurrence rate. However, the results remain controversial. Therefore, evidence-based evidence is needed to prove the advantages of Kono-S anastomosis.

To measure the influence of anastomosis techniques on the long-term relapse rate of CD by conducting a meta-analysis.

PubMed, Scopus, and Cochrane Library were searched until October 8, 2023. Patients who underwent intestinal resection due to CD were included. The intervention measures included Kono-S anastomosis, whereas the control group received traditional anastomosis such as end-to-end, end-to-side, and side-to-side anastomosis. Only randomized clinical trials and observational studies were included. The primary outcome measures were hospital stay post-surgery, overall postoperative complication incidence, the proportion of Clavien-Dindo grade IIIa or higher, overall postoperative recurrence rate, and Rutgeerts score.

From 2011 to 2023, six articles met the inclusion and exclusion criteria. The results indicated that Kono-S anastomosis can reduce the hospital stay post-surgery of patients with CD [MD = -0.26, 95%CI: -0.42 to -0.10, P = 0.002] than other traditional anastomosis methods. Compared to other traditional anastomosis methods, Kono-S anastomosis can significantly reduce the total recurrence rate [MD = 0.40, 95%CI: 0.17 to 0.98, P = 0.05] and postoperative Rutgeerts score [MD = -0.81, 95%CI: -0.96 to -0.66, P < 0.001] in patients with CD. However, there is no significant disparity in the overall occurrence of postoperative complications and the proportion of Clavien-Dindo ≥ IIIa.

Kono-S anastomosis has the potential to expedite the recuperation of CD and diminish relapse hazards; however, additional larger trials are necessary to authenticate its effectiveness.

(1) Background: we conducted this study to evaluate the effect of Kono-S anastomosis on postoperative morbidity after bowel resection for Crohn's disease. (2) Methods: This study adhered to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The primary endpoint was the overall complications rate. Secondary outcomes included specific complications analyses, disease recurrence and efficiency endpoints. A systematic literature screening was performed in major electronic scholar databases (Medline, Scopus, Web of Science), from inception to 17 January 2024. Both Random (RE) and Fixed Effects (FE) models were estimated; the reported analysis was based on the Cochran Q test results. (3) Results: Overall, eight studies and 913 patients were included in this meta-analysis. Pooled analyses confirmed that Kono-S was not superior in terms of overall morbidity (OR: 0.69 [0.42, 1.15], p = 0.16). Kono-S displayed a reduced risk for anastomotic leakage (OR: 0.34 [0.16, 0.71], p = 0.004) and reoperation (OR: 0.12 [0.05, 0.27], p < 0.001), and a shortened length of hospital stay (WMD: -0.54 [-0.73, -0.34], p < 0.001). On the contrary, Kono-S results in higher rates of postoperative SSIs (OR: 1.85 [1.02, 3.35], p = 0.04). (4) Conclusions: This study confirms a comparable morbidity, but a lower risk of anastomotic leak and reoperation of Kono-S over conventional anastomoses. Further high quality studies are required to validate these findings.

Postoperative recurrence is a major concern in Crohn's disease. The Kono-S anastomosis has been described to reduce the rate of recurrence. However, the level of evidence for its effectiveness remains low. The KoCoRICCO study aimed to compare outcomes between Kono-S anastomosis and conventional anastomosis in two nationwide, prospective cohorts.

Adult patients with Crohn's disease, who underwent ileocolonic resection with Kono-S anastomosis, were prospectively included in seven referral centres between 2020 and 2022. Patients with conventional side-to-side anastomosis were enrolled from a previously published cohort. A propensity score analysis was performed to compare recurrence at first endoscopy in a matched 1:2 ratio population.

A total of 433 patients with ileocolonic anastomosis were enrolled, of whom 155 had a Kono-S anastomosis. Before matching, both groups were unbalanced for preoperative, intraoperative, and postoperative characteristics. After matching patients with available endoscopic follow-up, endoscopic recurrence ≥i2 was found in 47.5% of the Kono-S group and 44.3% of the conventional side-to-side group [p = 0.6745].

The KoCoRICCO study suggests that Kono-S anastomosis does not reduce the risk of endoscopic recurrence in Crohn's disease compared with conventional side-to-side anastomosis. Further research with a longer follow-up is necessary to determine whether there is a potential benefit on surgical recurrence.

Crohn's disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract characterized by relapsing-remission phases. CD often requires surgical intervention during its course, mainly ileo-cecal/ileo-colonic resection. However, surgery in CD is not curative and post-operative recurrence (POR) can happen. The management of CD after surgery presents challenges. Ensuring timely, effective, and safe therapy to prevent POR is essential but difficult, considering that approximately 20-30% of subjects may not experience endoscopic POR and that 40-50% will only exhibit intermediate lesions, which carry a low risk of mid- and long-term clinical and surgical POR. Currently, there are two accepted intervention strategies: early post-operative prophylactic therapy (systematically or based on the patient's risk of recurrence) or starting therapy after confirming endoscopic POR 6-12 months after surgery (endoscopy-driven prophylactic therapy). The risk of overtreatment lies in exposing patients to undesired adverse events, along with the costs associated with medications. Conversely, undertreatment may lead to missed opportunities to prevent bowel damage and the necessity for additional surgery. This article aims to perform a comprehensive review regarding the optimal strategy to reduce the risk of POR in CD patients and the current therapeutic options.

The Kono-S anastomosis was introduced as a possible solution to the high surgical recurrence rates in Crohn's disease. However, this technique is known to be challenging, which is why it was originally performed in an extracorporeal setting. The aim of this case series was to assess safety, in terms of intra-/postoperative complications, and feasibility, in terms of successful performance of anastomosis, of a robot-assisted intracorporeal Kono-S anastomosis.

This is a prospective single-centre consecutive case series. Patients were considered eligible if they were diagnosed with refractory Crohn's disease with significant bowel stenosis of the terminal ileum. All patients underwent robot-assisted intracorporeal Kono-S anastomosis. Perioperative care was provided according to the Enhanced Recovery After Surgery® protocol. Follow-up for postoperative complications was 30 days.

Twenty patients were included, of whom 11 (55%) were men. The median age was 30 years [interquartile range (IQR) 22-51 years] and the median BMI was 25 kg/m2 (IQR 19-28 kg/m2). Intracorporeal Kono-S anastomosis was successfully performed in all cases. The median operating time was 155 min (IQR 144-176 min) and the median length of stay was 3 days (IQR 1-5 days). No conversions or 30-day mortality were observed. One patient experienced anastomotic leakage, which was treated with radiologically guided drainage. A total of three patients experienced postoperative complications in the first 30 days.

Performance of intracorporeal robot-assisted Kono-S anastomosis seems safe and feasible in this case series for Crohn's disease. Since this is a first case series, further research is required to confirm results in a larger population-based cohort.

Management of pediatric-onset Crohn's disease uniquely necessitates consideration of growth, pubertal development, psychosocial function and an increased risk for multiple future surgical interventions. Both medical and surgical management are rapidly advancing; therefore, it is increasingly important to define the role of surgery and the breadth of surgical options available for this complex patient population. Particularly, the introduction of biologics has altered the disease course; however, the ultimate need for surgical intervention has remained unchanged. This review defines and evaluates the surgical techniques available for management of the most common phenotypes of pediatric-onset Crohn's disease as well as identifies critical perioperative considerations for optimizing post-surgical outcomes.

Crohn's disease (CD) is a subtype of chronic and incurable inflammatory bowel disease. It can affect the entire gastrointestinal tract and its etiology is unknown.

The aim of this consensus was to establish the most relevant aspects related to definitions, diagnosis, follow-up, medical treatment, and surgical treatment of Crohn's disease in Mexico.

Mexican specialists in the areas of gastroenterology and inflammatory bowel disease were summoned. The consensus was divided into five modules, with 69 statements. Applying the Delphi panel method, the pre-meeting questions were sent to the participants, to be edited and weighted. At the face-to-face meeting, all the selected articles were shown, underlining their level of clinical evidence; all the statements were discussed, and a final vote was carried out, determining the percentage of agreement for each statement.

The first Mexican consensus on Crohn's disease was produced, in which recommendations for definitions, classifications, diagnostic aspects, follow-up, medical treatment, and surgical treatment were established.

Updated recommendations are provided that focus on definitions, classifications, diagnostic criteria, follow-up, and guidelines for conventional medical treatment, biologic therapy, and small molecule treatment, as well as surgical management.

The mesentery has recently been implicated in the pathophysiology of Crohn's disease (CD), and several techniques have been developed to target the mesentery to reduce its influence on recurrence. We aimed to describe short-term safety and feasibility after these approaches.

This is a comparative, retrospective, single-center cohort study of consecutive CD patients undergoing primary or redo ileocolic resection from 2015 to 2022 with Kono-S anastomosis (KSA), extended mesenteric excision (EME) only, or both: mesenteric excision and exclusion (MEE).

186 patients underwent KSA (n ​= ​74), EME (n ​= ​66), or MEE (n ​= ​46). The groups had comparable baseline characteristics. The MEE group operative time was longer (median: 187 vs. KSA 170, EME 152 ​min, p ​< ​0.01). Postoperatively, the groups had similar lengths of stay (median 4 days), readmissions (9.1 ​%), major postoperative complications (6.5 ​%), and anastomotic leaks (1.1 ​%).

Targeting the mesentery with novel surgical approaches for ileocolic Crohn's disease was safe and feasible for short-term follow-up.

Although surgical management of the ileocolic segment in pediatric Crohn's disease is not curative, the main goal of therapy is to allow for growth, adequate nutrition, and age-appropriate development. Recurrent disease at the site of anastomosis presents as a major morbidity. Several factors have been implicated in the development of surgical recurrence though data in the literature is scarce. This review explores the epidemiology of recurrent ileocolic disease following primary surgery, indications for surgical intervention, and techniques reported in the literature. Pediatric data is scarce, and therefore, much of it is extrapolated from adult literature.

Children diagnosed with Crohn's disease (CD) often undergo ileocecal resection (ICR) during childhood. Anastomotic recurrence is a frequent finding following this procedure. Data addressing the effect of the anastomosis type on disease recurrence are scarce in the pediatric population. The Kono-S anastomosis has shown promise in reducing endoscopic, clinical, and surgical recurrence rates in adults. We aimed to report our experience with Kono-S anastomosis in children, focusing on its feasibility and postoperative complications.

We retrospectively analyzed pediatric CD patients who underwent ICR with Kono-S anastomosis between August 2022 and May 2023. Data on demographics, clinical characteristics, surgery, hospitalization, and follow-up including colonoscopy were collected. Complications were classified using the Clavien-Dindo classification.

Twelve patients (7 females, 58.3%) were included. Six (50%) of the patients had the B3 luminal form of the disease (according to Paris classification). Median surgery duration was 174 (interquartile range [IQR] 161-216) minutes. Anastomosis creation took a median of 62 (IQR, 54.5-71) minutes. Median hospitalization length was 6 (IQR 4-7) days. No short- or mid-term complications were observed. Median follow-up duration was 9.5 (IQR 6.8-12) months.

According to our results, Kono-S anastomosis is safe and feasible in pediatric CD patients, with no observed postoperative complications. These findings support the potential benefit of using Kono-S anastomosis as a treatment approach in children with CD.

Guidelines advise to perform endoscopic surveillance following ileocolic resection (ICR) in Crohn disease (CD) for timely diagnosis of recurrence. This study aims to assess the variation in endoscopic recurrence (ER) rates in patients after ICR for CD using the most commonly used classification systems, the Rutgeerts score (RS) and modified Rutgeerts score (mRS) classifications.

A systematic literature search using MEDLINE, Embase, and the Cochrane Library was performed. Randomized controlled trials and cohort studies describing ER < 12 months after an ICR for CD were included. Animal studies, reviews, case reports (<30 included patients), pediatric studies, and letters were excluded. The Newcastle-Ottawa Quality Assessment Scale and Cochrane Collaboration's tool were used to assess risk of bias. Main outcome was the range of ER rates within 12 months postoperatively, defined as RS ≥ i2 and/or mRS ≥ i2b. A proportional meta-analysis was performed. The final search was performed on January 4, 2022. The study was registered at PROSPERO, CRD42022363208.

Seventy-six studies comprising 7751 patients were included. The weighted mean of ER rates in all included studies was 44.0% (95% confidence interval, 43.56-44.43). The overall range was 5.0% to 93.0% [interquartile range (IQR), 29.2-59.0]. The weighted means for RS and mRS were 44.0% and 41.1%, respectively. The variation in ER rates for RS and mRS were 5.0% to 93.0% (IQR, 29.0-59.5) and 19.8% to 62.9% (IQR, 37.3-46.5), respectively. Within studies reporting both RS and mRS, the weighted means for ER were 61.3% and 40.6%, respectively.

This study demonstrates a major variation in ER rates after ICR for CD, suggesting a high likelihood of inadequate diagnosis of disease recurrence, with potentially impact on quality of life and health care consumption. Therefore, there is an important need to improve endoscopic scoring of recurrent disease.

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

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

Retrospective study of prospectively collected patients.

Four tertiary referral centers.

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

Extracorporeal handsewn Kono-S anastomosis.

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

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

Retrospective study and variability of perioperative medical therapy.

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

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

The most common intestinal operation in Crohn's disease (CD) is an ileocolic resection. Despite optimal surgical and medical management, recurrent disease after surgery is common. Different types of anastomoses with respect to configuration and construction can be made after resection for example, handsewn (end-to-end and Kono-S) and stapled (side-to-side). The various types of anastomoses might affect endoscopic recurrence and its assessment, the functional outcome, and costs. The objective of the present study is to compare the three types of anastomoses with respect to endoscopic recurrence at 6 months, gastrointestinal function, and health care consumption.

This is a randomized controlled multicentre superiority trial, allocating patients either to side-to-side stapled anastomosis as advised in current guidelines or a handsewn anastomoses (an end-to-end or Kono-S). It is hypothesized that handsewn anastomoses do better than stapled, and end-to-end perform better than the saccular Kono-S. Two international studies with a similar setup will be conducted mainly in the Netherlands (End2End) and Italy (HAND2END). Patients diagnosed with CD, aged over 16 years in the Netherlands and 18 years in Italy requiring (re)resection of the (neo)terminal ileum are eligible. The first part of the study compares the two handsewn anastomoses with the stapled anastomosis. To detect a clinically relevant difference of 25% in endoscopic recurrence, a total of 165 patients will be needed in the Netherlands and 189 patients in Italy. Primary outcome is postoperative endoscopic recurrence (defined as Rutgeerts score ≥ i2b) at 6 months. Secondary outcomes are postoperative morbidity, gastrointestinal function, quality of life (QoL) and costs.

The research question addresses a knowledge gap within the general practice elucidating which type of anastomosis is superior in terms of endoscopic and clinical recurrence, functionality, QoL and health care consumption. The results of the proposed study might change current practice in contrast to what is advised by the guidelines.

NCT05246917 for HAND2END and NCT05578235 for End2End ( http://www.

gov/ ).

The role of visceral fat in disease development, particularly in Crohn´s disease (CD), is significant. However, its preoperative prognostic value for postoperative complications and CD relapse after ileocecal resection (ICR) remains unknown. This study aims to assess the predictive potential of preoperatively measured visceral and subcutaneous fat in postoperative complications and CD recurrence using magnetic resonance imaging (MRI). The primary endpoint was postoperative anastomotic leakage of the ileocolonic anastomosis, with secondary endpoints evaluating postoperative complications according to the Clavien Dindo classification and CD recurrence at the anastomosis.

We conducted a retrospective analysis of 347 CD patients who underwent ICR at our tertiary referral center between 2010 and 2020. We included 223 patients with high-quality preoperative MRI scans, recording demographics, postoperative outcomes, and CD recurrence rates at the anastomosis. To assess adipose tissue distribution, we measured total fat area (TFA), visceral fat area (VFA), subcutaneous fat area (SFA), and abdominal circumference (AC) at the lumbar 3 (L3) level using MRI cross-sectional images. Ratios of these values were calculated.

None of the radiological variables showed an association with anastomotic leakage (TFA p = 0.932, VFA p = 0.982, SFA p = 0.951, SFA/TFA p = 0.422, VFA/TFA p = 0.422), postoperative complications, or CD recurrence (TFA p = 0.264, VFA p = 0.916, SFA p = 0.103, SFA/TFA p = 0.059, VFA/TFA p = 0.059).

Radiological visceral obesity variables were associated with postoperative outcomes or clinical recurrence in CD patients undergoing ICR. Preoperative measurement of visceral fat measurement is not specific for predicting postoperative complications or CD relapse.