Ileocolic Crohn's Disease Research Articles

Idiopathic portal hypertension with regard to thiopurine treatment.

Idiopathic portal hypertension (IPH) is an infrequent adverse reaction to the use of thiopurines that tends to be overlooked. Herein, we present a patient with ileocolic Crohn's disease treated with azathioprine who presented ascites, esophageal varices and splenomegaly without any signs of liver cirrhosis. A portal hemodynamics study revealed a normal portosystemic gradient compatible with presinusoidal portal hypertension. Finally, IPH was diagnosed after a liver biopsy. IPH secondary to thiopurines is due to a 6-thioguanine nucleotide (6-TGN)-dependent reaction and occurs predominantly between three months and three years after the start of treatment. The onset is usually insidious and thrombocytopenia is the first manifestation. The definitive diagnosis is obtained by liver biopsy.

The association between intensified medical treatment, time to surgery and ileocolic specimen length in Crohn's disease.

During the last decade, treatment protocols have changed for patients with ileocolic Crohn's disease. Anti-tumour necrosis factor (anti-TNF) has become part of standard medical treatment, usually in a step-up approach. The aim was to analyse if improved medical treatment has resulted in more limited ileocolic resections and a longer interval between diagnosis and surgery. Patients undergoing ileocolic resection for Crohn's disease were included (1999-2014). Patient characteristics were compared to the results of a population-based study (between 2004 and 2010) previously performed in the catchment area of the present tertiary referral centre. Time trends were analysed using the Cochrane-Armitage trend, Spearman's correlation coefficient and linear regression. In total, 195 patients undergoing ileocolic resection were included. Patient characteristics were not significantly different from the background cohort, confirming a representative study group. Sixty-three patients were men (32.3%, median age at surgery 30.0years, interquartile range 23.0-40.0). Anti-TNF and immunomodulator use prior to surgery increased significantly during the study period (χ2 =49.1, P<0.001). Over the years, a significant increase in time from diagnosis to operation was found (median 39.0months, interquartile range 12.0-86.0, rho 0.175, P=0.014). The length of the resected ileum did not change significantly (median 20.0cm, interquartile range 12.0-30.0, rho -0.107, P=0.143). The number of fistulas or postoperative complications that needed re-intervention was not significantly different between the groups with or without anti-TNF. This study demonstrated that over time patients with ileocolic Crohn's disease who eventually underwent ileocolic resection have been treated more intensively medically; however, this did not result in reduced specimen size.

The accuracy of preoperative imaging in measuring the length of the ileocolic segment affected by Crohn's disease: a prospective cohort study.

The study aimed to evaluate the accuracy of imaging for measurement of the length of the ileocolic segment affected by Crohn's disease. Fifty-four consecutive patients who underwent resection between 2011 and 2014 for ileocolic Crohn's disease were prospectively studied. All had preoperative MR or CT enterography. Two independent radiologists measured the length of the diseased intestinal segment. The measurements were compared with the length of disease assessed on pathology of the non-fixed surgical specimen. The median preoperative length of the Crohn's disease segment on imaging was 20.5 (2-73) cm and 20 (3-90) cm, as measured by the two radiologists. Interobserver agreement was substantial (κ=0.69) with a correlation coefficient (r) of 0.82 (P<0.001). The median length of the Crohn's disease segment on pathological examination was 16.5 (2-75) cm and was closely correlated with the radiological measurement (r=0.76, P<0.001). The length of the Crohn's disease segment on imaging was correct to within 5cm of the value on pathology. It was correct in 30 (55%) patients and was underestimated and overestimated in 6 (11.1%) and 18 (33.3%). A length of disease of less than 20cm found on imaging in 26 patients was confirmed in 25 (96%) on pathology, whereas a length of more than 20cm found on imaging in 28 patients was confirmed in 18 (64%) on pathology. The sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of imaging for predicting a length of less than 20cm were 71%, 95%, 96%, 64% and 79%. Imaging accurately identifies the length of the ileocolic segment of Crohn's disease when it is 20cm or less on pathological examination. In patients with more extensive disease, imaging tends to overestimate the length and should be interpreted with caution.

From Risk Scales to Subclinical Atherosclerosis Quantification Through Non-invasive Imaging: Toward a New Paradigm in Cardiovascular Risk Prediction

The optimal treatment for an intra-abdominal abscess/infection secondary to perforating ileocolic Crohn's disease (PCD) is unclear.Forty-seven consecutive PCD patients treated via an institutional protocol of ileocolectomy after a 7-day period of percutaneous abscess drainage were retrospectively compared with 160 consecutive patients who underwent an elective ileocolectomy for Crohn's disease (ECD) between 1992 and 2014. Outcomes were compared using univariate analysis and propensity score matching.Univariate analysis demonstrated significant differences in ileostomy rates (PCD: 48.9% vs ECD: 18.8%; P = .001), 30-day readmissions (PCD: 38.3% vs ECD: 18.8%; P = .01), and overall 30-day postoperative complications (PCD: 29.8% vs ECD: 15%; P = .03). After matching, a statistically significant difference was retained in ileostomy rates (P = .02) and 30-day readmissions (P = .01).Early operative intervention after percutaneous drainage in perforating CD may be associated with a high incidence of diversions and readmissions.

P216 Mesenteric disease is directly related to mucosal disease in Crohn's disease

Background: Crohn's disease (CD) displays mesenteric disease manifestations such as fat wrapping and mesenteric thickening. The frequency at which these occur in CD point to a pathobiological relevance. Fat wrapping in particular has been suggested to play a role in disease progression [1]. This study aimed to evaluate the relationship between mesenteric disease and other manifestations of CD and to examine the significance of advanced mesenteric disease. Methods: Ethical approval and informed consent were obtained from the HSE Mid-Western Regional Hospital Research Ethics Committee. All patients undergoing resection for ileocolic CD in University Hospital Limerick since 2010 have undergone a resection which included the mesentery. Novel disease activity indices were generated to quantify mesenteric and mucosal disease. Mesenteric disease was graded based on the presence and extent of mesenteric thickening and fat wrapping (Table 1A). Mucosal disease was graded based on the presence of different intestinal features of CD (Table 1B). Pre-operative Crohn's disease activity index (CDAI) was recorded for all patients. The effect of smoking on all disease activity indices was investigated. The relationship between histologic fat wrapping and surgical recurrence was determined in all intestinal forms of CD (n=94). Table 1A. Mesenteric disease activity index in Crohn's disease Key: FW = fat wrapping, MT = mesenteric thickening. Table 1B. Mucosal disease activity index in Crohn's disease Results: Mucosal and mesenteric disease were topographically coupled in all resection specimens examined. There was a direct association between mesenteric and mucosal disease when investigated using the novel disease activity indices (r=0.78, p<0.0001). Higher CDAI scores were associated with higher mesenteric and mucosal disease scores (r=0.72; r=0.70, respectively, p<0.0001). Patients who smoked had more severe mesenteric disease (p<0.05) but there was no effect on mucosal disease or CDAI. Fat wrapping was observed histologically in 13 (41.9%) index resection specimens and 18 (72%) recurrence specimens. Fat wrapping was an independent predictor of increased risk of surgical recurrence (HR 4.7, 95% CI: 1.71–13.01, p=0.003) and was also associated with a shortened time to recurrence (p<0.001). Conclusions: There was a direct association between mesenteric disease and mucosal disease manifestations. Fat wrapping independently predicted surgical recurrence and was associated with a shortened time to recurrence.

P420 Anti-TNF for post-operative prevention in Crohn's disease: the detection of anti-drug antibodies at time of surgery is associated with an increased risk of endoscopic recurrence

Background: Anti-TNF monoclonal antibodies (mAb) are efficient for the prevention of postoperative recurrence in Crohn's disease (CD). Measurement of trough serum levels and anti-drug antibodies may help to determine the mechanisms of anti-TNF failure. We previously identified two risk factors associated with endoscopic recurrence in the REMIND cohort: tobacco (OR =2.3) and anti-TNF (OR =0.35). The aim of our study was to correlate efficacy of anti-TNF mAb with their pharmacokinetics within the same cohort. Methods: The REMIND group conducts a prospective nationwide study in nine French academic centers of ileal and/or ileocolic CD patients. Samples are taken from the surgical specimen at the time of surgery (M0) and at the time of endoscopy (M6), stored centrally in a bio-bank, and analyzed to identify factors associated with recurrence. This study was performed in the 60 patients treated post-operatively with anti-TNF in the REMIND cohort (198 patients included on the date of the analysis). The trough levels of infliximab (IFX) and adalimumab (ADA) and anti-drug antibodies (ATI and ATA) were analyzed by ELISA method. Limits of detection were 10 ng/ml for both ATI and ATA. Trough levels of detection of anti-TNF drugs was 0.3 μg/ml. Therapeutic thresholds levels were 3 μg/ml for IFX and 4,9 μg/ml for ADA. Endoscopic recurrence was defined by a Rutgeerts ≥ i2 score. The fisher test was used for the bivariate analysis. Results: Sixty subjects received an anti-TNF agent (ADA n=47, IFX n=8) after surgery. Only 14 patients (23%) were naive of anti-TNF. Twenty-six patients (43%) had an endoscopic recurrence and 34 (57%) had a normal colonoscopy. ATA or ATI were detected in 8 patients at M0; 6 of them (75%) had an endoscopic recurrence. In contrast, of the 41 patients who did not have anti-drug antibodies at the time of surgery, 13 (32%) had endoscopic recurrence (p=0.04). At M6, the trough drug levels were analyzed in 32 patients. In the group of patients with endoscopic recurrence, trough drug levels were below therapeutic threshold in 10 of 15 patients (67%) compared to the 3/17 patients (18%) in the group of patients with endoscopic remission (p=0.01). Conclusions: The presence of anti-drug antibodies at the time of surgery is associated with a higher risk of endoscopic recurrence. Infra-therapeutic trough levels at M6 were associated with a higher risk of endoscopic recurrence. In clinical practice, these results demonstrate that detection of anti-drug antibodies may influence the choice of postoperative therapy.

Efficacy and Safety of Oral Budesonide in Patients with Active Crohn's Disease in Japan: A Multicenter, Double-Blind, Randomized, Parallel-Group Phase 3 Study

Background: US and European guidelines recommend budesonide for the treatment of mild-to-moderate active ileocolic Crohn's disease (CD). However, budesonide has not been approved, and mesalazine is widely used as first-line treatment in Japan. The objective of this study was to evaluate the efficacy and safety of budesonide in patients with mild-to-moderate active CD in Japan. Methods: In this phase 3 noninferiority study (NCT01514240), 112 patients with a baseline Crohn's Disease Activity Index (CDAI) score of 180-400 were randomized to budesonide or mesalazine for 8 weeks. Assessments included remission rate (CDAI score ≤150) at weeks 2, 4, and 8, change in CDAI score, health-related quality of life (measured using the Inflammatory Bowel Disease Questionnaire [IBDQ]), and tolerability. Results: The remission rate at week 8 was numerically higher in the budesonide group (30.4%) than in the mesalazine group (25.0%), and the noninferiority of budesonide to mesalazine was shown. The mean total CDAI score decreased to a greater extent with budesonide than with mesalazine. Mean IBDQ scores improved from baseline to weeks 2, 4, 8, and 10 in both groups; improvements were numerically higher with budesonide than with mesalazine. No safety concerns were found. Conclusion: Budesonide is comparably effective to mesalazine in the treatment of Japanese patients with mild-to-moderate active CD.

Peripheral blood methylation profiling of female Crohn's disease patients.

BackgroundCrohn’s disease (CD) is a chronic inflammatory disorder belonging to the inflammatory bowel diseases (IBD). CD affects distinct parts of the gastrointestinal tract, leading to symptoms including diarrhea, fever, abdominal pain, weight loss, and anemia. The aim of this study was to assess whether the DNA methylome of peripheral blood cells can be associated with CD in women.MethodsSamples were obtained from 18 female patients with histologically confirmed ileal or ileocolic CD and 25 healthy age- and gender-matched controls (mean age and standard deviation: 30.5 ± 6.5 years for both groups). Genome-wide DNA methylation was determined using the Illumina HumanMethylation 450k BeadChip.ResultsOur analysis implicated 4287 differentially methylated positions (DMPs; corrected p < 0.05) that are associated to 2715 unique genes. Gene ontology enrichment analysis revealed significant enrichment of our DMPs in immune response processes and inflammatory pathways. Of the 4287 DMPs, 32 DMPs were located on chromosome X with several hits for MIR223 and PABPC5. Comparison with previously performed (epi)genome-wide studies revealed that we replicated 33 IBD-associated genes. In addition to DMPs, we found eight differentially methylated regions (DMRs).ConclusionsCD patients display a characteristic DNA methylation landscape, with the differentially methylated genes being implicated in immune response. Additionally, DMPs were found on chromosome X suggesting X-linked manifestations of CD that could be associated with female-specific symptoms.Electronic supplementary materialThe online version of this article (doi:10.1186/s13148-016-0230-5) contains supplementary material, which is available to authorized users.

Outcomes of early ileocolectomy after percutaneous drainage for perforated ileocolic Crohn's disease

BackgroundThe optimal treatment for an intra-abdominal abscess/infection secondary to perforating ileocolic Crohn's disease (PCD) is unclear. MethodsForty-seven consecutive PCD patients treated via an institutional protocol of ileocolectomy after a 7-day period of percutaneous abscess drainage were retrospectively compared with 160 consecutive patients who underwent an elective ileocolectomy for Crohn's disease (ECD) between 1992 and 2014. Outcomes were compared using univariate analysis and propensity score matching. ResultsUnivariate analysis demonstrated significant differences in ileostomy rates (PCD: 48.9% vs ECD: 18.8%; P = .001), 30-day readmissions (PCD: 38.3% vs ECD: 18.8%; P = .01), and overall 30-day postoperative complications (PCD: 29.8% vs ECD: 15%; P = .03). After matching, a statistically significant difference was retained in ileostomy rates (P = .02) and 30-day readmissions (P = .01). ConclusionsEarly operative intervention after percutaneous drainage in perforating CD may be associated with a high incidence of diversions and readmissions.

A case of asymptomatic Sjögren's syndrome who developed interstitial pneumonia during monoclonal antibody therapy of Crohn's disease

A 67-year-old woman was diagnosed with ileocolic Crohn's disease at 61 years of age. Remission had been induced by the monoclonal antibody adalimumab, and maintenance therapy had continued since her diagnosis. However, she developed respiratory symptoms, including a dry cough. A chest CT scan revealed interstitial shadows in the lower pulmonary lobes. Although no sicca symptoms were noted, she was serologically positive for both anti-Sjögren's syndrome-related antigen A and B antibodies, and salivary gland biopsy showed lymphocytic infiltration. Consequently, she was diagnosed as having asymptomatic Sjögren's syndrome. Infection or drug-induced pulmonary disease was considered unlikely, and the interstitial pneumonia was considered an extra-glandular presentation of Sjögren's syndrome. Thus, interstitial shadows, which appear during immunotherapy for Crohn's disease, could indicate asymptomatic Sjögren's syndrome; clinicians should consider this rare clinical picture when assessing such a patient.

Outcomes following surgery for perforating Crohn's disease

The most common indications for surgery for patients with ileocolic Crohn's disease are fibrostenotic or perforating disease. The objective was to compare surgical outcomes of patients with perforating versus non-perforating disease following ileocolic resection. This was a retrospective review of all patients who had their first ileocolic resection between 1990 and 2010, identified from a prospectively maintained inflammatory bowel disease database. Demographic information, preoperative medication, intraoperative findings and postoperative outcome data were collected. Outcomes in patients who had an abscess drained before surgery or were found to have a fistula or abscess at surgery or at pathology were compared with outcomes in all others. A total of 434 patients (56·2 per cent women) were included, 293 with perforating and 141 with non-perforating disease. Median age, tobacco use, and preoperative steroid and biological agent use were similar in the two groups. Forty patients (13·7 per cent) in the perforating group had abscesses drained before surgery and 251 patients had at least one fistula, most commonly to the sigmoid colon. Patients with perforating disease were more likely to require preoperative total parenteral nutrition, need another resection, have an ileostomy and a longer mean postoperative stay, and less likely to undergo a laparoscopic procedure. Patients in this group also developed more postoperative abscesses or leaks (4·8 versus 0 per cent; P = 0·006). The reoperation rate was similar (3·1 versus 0·7 per cent; P = 0·178). Patients with penetrating Crohn's disease are more likely to require a more complex procedure, and an ileostomy, and to a have longer postoperative stay.

Study of the Viral and Microbial Communities Associated With Crohn's Disease: A Metagenomic Approach

OBJECTIVES:This study aimed to analyze and compare the diversity and structure of the viral and microbial communities in fecal samples from a control group of healthy volunteers and from patients affected by Crohn's disease (CD).METHODS:Healthy adult controls (n=8) and patients affected by ileocolic CD (n=11) were examined for the viral and microbial communities in their feces and, in one additional case, in the intestinal tissue. Using two different approaches, we compared the viral and microbial communities in several ways: by group (patients vs. controls), entity (viruses vs. bacteria), read assembly (unassembled vs. assembled reads), and methodology (our approach vs. an existing pipeline). Differences in the viral and microbial composition, and abundance between the two groups were analyzed to identify taxa that are under- or over-represented.RESULTS:A lower diversity but more variability between the CD samples in both virome and microbiome was found, with a clear distinction between groups based on the microbiome. Only ≈5% of the differential viral biomarkers are more represented in the CD group (Synechococcus phage S CBS1 and Retroviridae family viruses), compared with 95% in the control group. Unrelated patterns of bacteria and bacteriophages were observed.CONCLUSIONS:Our use of an extensive database is critical to retrieve more viral hits than in previous approaches. Unrelated patterns of bacteria and bacteriophages may be due to uneven representation of certain viruses in databases, among other factors. Further characterization of Retroviridae viruses in the CD group could be of interest, given their links with immunodeficiency and the immune responses. To conclude, some methodological considerations underlying the analysis of the viral community composition and abundance are discussed.

Transverse Incisions for Resection of Ileocolic Crohn's Disease

Laparoscopic ileocecectomy is advocated as the ideal surgical approach for ileocecal Crohn's disease. Our experience suggests that equivalent outcomes are accomplished through a small right lower quadrant (RLQ) transverse incision in this patient population. We conducted a retrospective chart review of 39 patients undergoing ileocectomy for Crohn's disease using a RLQ transverse incision between 1991 and 2009. The mean operative time was 99 minutes with a mean length of hospital stay of 4.2 days and mean duration until return of bowel function of 2.9 days. There were no deaths or major complications. Long-term follow-up revealed four patients (13%) who required hospitalization for small bowel obstructions, one patient (3%) developed an incisional hernia, and no patients required an ileostomy. Ileocecectomy performed for Crohn's disease using a RLQ transverse incision yielded similar hospital lengths of stay and time to return of bowel function as those published for laparoscopic resection. This approach may result in shorter operative times when compared with the inexperienced surgeon performing a laparoscopic resection. Long-term follow-up revealed the risk for future RLQ ileostomy is low and the development of hernias or bowel obstruction is unlikely.

West Nile Virus Meningoencephalitis during Treatment of Crohnʼs Disease with Adalimumab

Purpose: A 72-year-old male with longstanding history of ileocolic Crohn's disease presented with one week of high grade fevers, fatigue, headache and declining mental status. The patient was diagnosed with inflammatory bowel disease 23 years prior and for two decades was stable on a regimen which included 6-mercaptopurine (6-MP) and mesalamine. Two years prior to admission he developed worsening diarrhea and following a colonoscopy showing active colitis was started on Infliximab and steroids. Symptoms improved however recurred upon steroid taper. Infliximab therapy was escalated and he was transitioned from 6-MP to Methotrexate with improvement, but incomplete disease control. Due to ongoing symptoms patient was switched to adalimumab, which was later escalated to 80 mg every other week. Patient was having 8-9 solid bowel movements daily at the time of admission. On presentation the patient's systolic blood pressure was greater than 200 mmHg. Brain imaging did not reveal any acute changes. He was admitted to the ICU where blood pressure was stabilized and broad spectrum antibiotics were initiated, however his mental status continued to decline. He underwent lumbar puncture which was notable for opening pressure of 160 mmHg, consistent with aseptic meningitis. He was started on acyclovir but continued to deteriorate; within days he developed septic shock and respiratory failure secondary to MRSA pneumonia. Electroencephalogram demonstrated nonspecific slowing and extensive infectious work up resulted in serology positive for West Nile virus. Despite supportive efforts, his condition worsened over a 3 week period and per the family's wishes he was palliatively extubated. It was later discovered that the patient was bitten by a mosquito while gardening shortly before admission. The introduction of anti tumor necrosis factor alpha (TNF α) therapy in the late 1990s significantly expanded the armamentarium for the management of IBD. These agents have proven effective in treating Ulcerative colitis and Crohn's disease and thus their use has become common practice. Unfortunately, treatment related infections are known to occur. In vitro studies have demonstrated a neuroprotective role of TNF α in West Nile virus infection. Inhibitors of the TNF α response thus theoretically prolong viremia and increase penetration into the CNS. Here we describe a case of fatal West Nile virus meningoencephalitis in the setting of Crohn's disease treatment with adalimumab. A heightened awareness of mosquito-borne infections and monitoring for early symptoms of West Nile virus infection are encouraged for patients receiving anti TNF α therapy because of theoretically increased susceptibility to severe disease.

Enteral nutrition to suppress postoperative Crohn’s disease recurrence: a five-year prospective cohort study

The aim of this study was to investigate the long-term effect of enteral nutrition (EN) as a maintenance therapy in Crohn's disease (CD) patients following surgery. This study was an extension of our previous study to prolong the duration of intervention and follow-up from 1 to 5 years. Forty consecutive patients who underwent resection for ileal or ileocolic CD were included. Following surgery, 20 patients received continuous elemental diet infusion during the nighttime plus a low-fat diet during the daytime (EN group). Another 20 patients received neither nutritional therapy nor food restriction (control group). All patients were followed for 5 years after operation. No patient received corticosteroid, immunosuppressants, or infliximab except patients who developed recurrence. The end point of this study was recurrence requiring biologic therapy or reoperation. Recurrence rates were analyzed on an intention-to-treat basis. In the EN group, four patients could not continue tube intubation for elemental diet intake. Two patients (10 %) in the EN group and nine patients (45 %) in the control group developed recurrence requiring infliximab therapy (P = 0.03). The cumulative recurrence incidence rate requiring infliximab was significantly lower in the EN group vs the control group (P = 0.02). One patient (5 %) in the EN group and five patients (25 %) in the control group required reoperation for recurrence (P = 0.18). The cumulative incidence of reoperation was lower in the EN group vs the control group, the difference not being significant (P = 0.08). The outcomes of this study suggest that EN therapy reduces the incidence of postoperative CD recurrence.

Reversible Henoch–Schönlein purpura complicating adalimumab therapy

The tumour necrosis factor antagonists have demonstrated efficacy in the induction of remission and its maintenance in numerous chronic inflammatory conditions. These agents are generally well tolerated but with the increasing number of patients receiving anti-tumour necrosis factor-α (anti-TNFα) therapy, more adverse reactions are expected to occur. Cutaneous eruptions complicating treatment with anti-TNFα agents are common, occurring in around 20% of patients. Most reactions are mild-to-moderate and rarely warrant treatment withdrawal.We herein present a case of Henoch–Shönlein purpura (HSP) vasculitis following treatment with the monoclonal anti-TNFα antibody adalimumab for ileo-colic Crohn's disease. The reaction occurred after 18months of adalimumab therapy and discontinuation of the anti-TNFα resulted in rapid improvement of the condition. The causal relationship has become even more likely when the purpura reappeared after restarting adalimumab. The patient started infliximab, with disease control and no cutaneous side effects.To the best of our knowledge, this is the second case report of HSP complicating adalimumab therapy. Although adalimumab is theoretically less related to immune-mediated reactions, clinicians must be aware that adverse side effects may still occur. This is the first case that shows that infliximab can be safely used in patients with adalimumab related HSP. We discuss the literature and potential causal mechanisms and propose possible approaches to its management.

Laparoscopic Surgery for Recurrent Crohn's Disease

In spite of the recent improvements in drug therapy, surgery still represents the most frequent treatment for Crohn's disease (CD) complications. Laparoscopy has been widely applied over the last twenty years in colorectal surgery and was associated with lower postoperative pain, shorter hospitalization, faster return to daily activities, and better cosmetic results. Laparoscopy experienced a slower diffusion in inflammatory bowel disease surgery than in oncologic colorectal surgery, but proved to be safe and effective, and is currently considered the gold standard for the treatment of primary uncomplicated ileocolic CD. Indications for laparoscopy in CD have recently been widened to embrace more complicated or recurrent CD. This paper reviews the available data on the subset of recurrent CD patients. The reported results indicate that laparoscopy may be safely applied even in selected recurrent CD cases in hands of IBD surgeons with broad laparoscopic experience.

Crohn’s disease: prevalence of intestinal and extraintestinal manifestations detected by computed tomography enterography with water enema

Computed tomography enterography (CTE) may detect the presence, severity, and extent of bowel inflammation in patients with Crohn's disease (CD). The aim of our study was to assess, among a cohort of 22 histologically proven CD patients, the prevalence of disease distribution, behavior, anastomotic recurrence and extraintestinal manifestations detected by an original CTE technique. Two radiologists reviewed 221 CTEs performed providing both small and large bowel distension by oral administration of neutral contrast material and trans-rectal introduction of a water enema (CTE-WE). Ileal CD was detected in 116 CTE-WEs (52.4%), including 71/116 (61.2%) non-stricturing/non-penetrating, 17/116 (14.6%) stricturing, and 28/116 (24.1%) penetrating forms. Colonic CD was appreciable in 35 (15.8%) patients, including 18/35 (51.4%) non-stricturing/non-penetrating, 6/35 (17.1%) stricturing, and 11/35 (31.4%) penetrating forms. Ileocolic CD was present in 52 (23.5%) CTE-WEs, including 30/52 (57.7%) non-stricturing/ non-penetrating; 3/52 (5.7%) stricturing, and 19/52 (36.5%) penetrating forms. In 10/221 patients (4.5%), upper gastrointestinal involvement (UGI) was present. Perianal disease was observed in 17/221 patients (7.7%). Fistulas were present in 52 (23.5%) and abscesses in 24 (10.8%) CTE-WEs, respectively. Among 57/221 (25.8%) patients who had undergone a disease-related intestinal resection, in 30/57 cases (52.6%) CD recurrence at the anastomosis was present. 4/221 patients (1.8%) with a histologically confirmed intestinal neoplastic stenosis were observed. Sacroiliitis (24%) was found to be prevalent over hepatic steatosis (10.8%), cholelithiasis (8.6%), and nephrolithiasis (4%). CTE-WE represents a comprehensive imaging technique which may demonstrate bowel inflammation and CD extraintestinal manifestations. A peculiar prevalence of UGI involvement and neoplastic strictures were observed. In our study the prevalence of sacroiliitis resulted higher than previously reported.

Laparoscopic surgery for recurrent ileocolic Crohn’s disease is as safe and effective as primary resection

The safety and short-term outcome of laparoscopic surgery for recurrent ileocolic Crohn's disease was compared with the outcome following primary resection. Between June 2002 and June 2010, 59 consecutive unselected patients (30 of whom had recurrent disease) underwent laparoscopic ileocolic resection. Four primary resections and one revision were performed as a single incision laparoscopic surgery (SILS) procedure. There was no difference between the two groups in terms of age, body mass index, American Society of Anesthesiology (ASA) grade or the presence or absence of fistulating disease. The median operating time was significantly longer for the revision group (125 min vs 85 min; P < 0.001). The rate of conversion was 8.5%, morbidity was 20% and mortality was 0% (P = not significant between groups). Risk factors for conversion included a complex fistula, fibrosis and the need to carry out multiple stricturoplasty. Patients in whom surgery was converted had a longer hospital stay and a higher morbidity (40%). The median hospital stay was 3 days, the return to theatre rate was 5% and the re-admission rate was 5% (P = not significant between groups). Laparoscopic surgery for recurrent ileocolic Crohn's disease is safe and can lead to significant short-term benefit, including earlier discharge. Conversion increases the length of stay in hospital and the overall morbidity.

Early experience with single-site laparoscopic surgery for complicated ileocolic Crohn’s disease at a tertiary-referral center

The role of single-site laparoscopy (SSL) for the treatment of ileocolic Crohn's disease complicated by an abscess, a phlegmon, or fistulizing disease has not been thoroughly assessed. A prospectively maintained database of SSL surgeries performed between October 2010 and March 2011 was reviewed. Consecutive patients with ileocolic Crohn's disease complicated by a paracolic abscess, a phlegmon, or a fistula were included for analysis. Data recorded included demographic information, body mass index (BMI), estimated blood loss (EBL), length of surgery, rate of conversion to standard laparoscopic surgery or open surgery, length of hospital stay, and rate of complications. A total of six patients were identified. Complications from Crohn's disease included four (66%) patients who developed a paracolic abscess that required drainage upon admission, one (16%) patient who developed a phlegmon, and one (16%) patient who developed an enterocutaneous fistula. Mean age of the study population was 25 years, with a mean BMI of 21 and a mean ASA score of 3. Five (83%) of the patients were immunosuppressed with high-dose steroids. Mean operative time was 160 min, with a median EBL of 60 mL. One patient required the insertion of an additional trocar, whereas there were no conversions to laparotomy. Four (66%) patients required diversion with a loop ileostomy. Median time to flatus was 1 day. All patients tolerated a diet on the day of surgery, with a median length of stay of 3 days. There were no deaths and no complications related to bleeding, organ injury, surgical site infections, or anastomotic leaks. A single-site laparoscopic approach for complicated ileocolic Crohn's disease can be performed safely, with short lengths of hospital stay and with a low rate of complications. A multicenter study would be beneficial to validate these findings.