Does End-to-End vs Side-to-Side Anastomosis in Postoperative Crohn’s Disease Matter? Prospective 2-Year Evaluation of Postoperative Quality of Life, Health Care Utilization, and Clinical Activity

Abstract

Introduction: Surgery is required in the majority of ileocolonic and small bowel Crohn’s disease (CD) patients. Surgical technique and anastomotic reconstruction has evolved with a shift from handsewn end-to-end anastomosis (ETEA) towards stapled side-to-side anastomosis (STSA). ETEA is technically more difficult as it reconstructs the intestine as an intact tube, while STSA is constructed rapidly, but will transect circular muscle layers creating a pouch like, anti-peristaltic configuration at the anastomosis (ie “functional end-to-end” anastomosis). Prospective studies show no difference between ETEA and STSA regarding early 30 day complications, but there is limited data regarding impact of anastomosis type on long term quality of life (QoL) and healthcare utilization in post-op CD patients beyond 1 year. Methods: This was a prospective observational study of postoperative CD patients in a consented natural history registry who underwent their first or second small bowel resection/reanastomosis with 2 year follow-up. Patients were categorized as ETEA or STSA based on operative reports. Postoperative QoL was assessed with short inflammatory bowel disease (SIBDQ) scores obtained at clinic visits. Healthcare utilization included emergency department (ED) visits, hospitalizations, imaging and repeat abdominal surgeries. Results: A total of 114 postoperative CD patients (56 ETEA; 58 STSA) were included. There was no difference in baseline characteristics between ETEA and STSA groups regarding age (36 vs. 40 years; p=0.2), gender (53% vs. 50% male; p=0.7), active smoking (30% vs. 24 %; p=0.5), penetrating disease behavior (41% vs. 38%; p=0.7), duration of CD (7.7 vs. 10.4 yrs; p=0.1), rates of laparoscopic surgery (78% vs. 72%; p=0.5) and use of postoperative prophylaxis with immunomodulators and/or biologics (87.5% vs. 75.9%; p=0.15). At 2 years postoperative, ETEA patients had significantly lower rates of CT scans (12.5% vs. 48.3%; p=0.0001), MRI scans (0% vs. 10%; p=0.027), ED visits (14% vs. 31%; p=0.04), hospitalizations (10% vs. 27%; p=0.03) and better QoL (SIBDQ 52.9 vs. 47.6; p=0.03) compared with STSA patients. There was no difference between ETEA and STSA patients regarding rates of overall postoperative surgical procedures (5.4% vs. 13.8 %; p=0.2), repeat bowel resection (3.6% vs. 6.9%; p=0.7) and postoperative complications (6.6% vs. 5.6%; p=0.7). Postoperative endoscopic recurrence rates were lower amongst ETEA patients compared to STSA patients (19.6% vs. 41.8%; p=0.019). One patient in the STSA group died at 2 years postoperative due to narcotic overdose. Conclusion: Surgical anastomosis type impacts functional status of postoperative CD in the present era of immunomodulator and biologic therapy. At 2 years postoperative, patients with ETEA have better QoL, less clinical activity and less healthcare utilization compared with STSA, while receiving similar postoperative CD treatment.