Ileocolic Resection For Crohn Research Articles

Optimising surgical anastomosis in ileocolic resection for Crohn’s disease with respect to recurrence and functionality: two international parallel randomized controlled trials comparing handsewn (END-to-end or Kono-S) to stapled anastomosis (HAND2END and the End2End STUDIES)

BackgroundThe 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.MethodsThis 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.DiscussionThe 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.Trial registrationNCT05246917 for HAND2END and NCT05578235 for End2End (http://www.clinicaltrials.gov/).

P526 Handsewn versus Stapled Ileocolic Anastomosis for Crohn's: Comparable Outcomes Despite More Severe Disease Profile in the Handsewn Group

Abstract Background Stapled anastomosis is the most common anastomotic method after ileocolic resection for Crohn's disease, whereas handsewn end-to-end (HS-ETE) anastomosis is less frequently performed. The optimal technique for ileocolic anastomosis in Crohn's patients remains controversial. Some studies have suggested potential benefits of HS-ETE over SSTS, including lower recurrence rates, whereas others have found no difference. We aimed to compare short-term postoperative outcomes and long-term recurrence-free survival between the HS-ETE and SSTS groups at our center. Methods This retrospective study included consecutive patients who underwent ileocolic resection for Crohn's disease between 2012-2022 with either HS-ETE or SSTS anastomosis. The primary outcomes were perianastomotic recurrence and need for surgical/endoscopic intervention. Cox regression and Kaplan-Meier curves were used to compare recurrence-free survival. Results A total of 764 patients were included: 162 (21%) with HS-ETE and 602 (79%) with SSTS anastomosis. The median age of the HS-ETE and SSTS groups was 39 and 38 years, respectively. Males comprised 43% of the HS-ETE group and 51% of the SSTS group. The median BMI was 24 kg/m2 in both groups. The HS-ETE group had a longer median disease duration (10 vs. 7 years, p=0.02) and a higher rate of previous abdominal surgery (35% vs. 22%, p=0.01) than the SSTS group did. The ileocolonic location (78% vs. 66%, p=0.03) and perforating disease (45% vs. 35%, p=0.04) were also more common in the HS-ETE group. The median operative time (207 min vs. 147 min, p<0.001) and estimated blood loss (150 mL vs. 75 mL, p<0.001) were greater in the HS-ETE group. There were no differences in 30-day outcomes between the groups. Perianastomotic recurrence rates were similar between the HS-ETE and SSTS groups (29.6% vs. 28.9%, p=0.93). The 5-year recurrence-free survival rates were also comparable (HS-ETE, 56.4% vs. SSTS, 59%; p=0.94). Also, we found that the risk of requiring surgical or endoscopic intervention for recurrence between HS-ETE and SSTS was comparable (HS-ETE, 65.2% vs. SSTS, 74.2%; p=0.273) Conclusion Although the HS-ETE group had worse baseline disease characteristics, including longer disease duration, higher previous surgery rates, and more aggressive disease location and behavior, HETE and SSTS anastomosis after ileocolic resection for Crohn’s disease yielded comparable perioperative and long-term outcomes in our patient cohort.

P575 Kono-S anastomosis reduces post-op intervention after ileocolic resection for Crohn’s disease

Abstract Background Ileocolic resection and anastomosis is the most common intestinal operation for Crohn's disease (CD). However, the choice of anastomosis remains a topic of debate. The SUPRME CD randomized trial demonstrated decreased rates of surgical recurrence after Kono-S anastomosis (KSA). We aimed to compare the long-term recurrence-free survival between KSA and stapled side-to-side (SSTS) anastomosis in a retrospective cohort. We hypothesized that KSA was associated with a lower risk of postoperative recurrence requiring intervention than SSTS. Methods We included consecutive patients from a prospectively maintained database who underwent ileocolic anastomosis for terminal ileal CD between 2020 and 2022. Patients with other types of anastomoses were excluded. The short-term postoperative outcomes and interventions for perianastomotic recurrence were compared between the two groups. Results Overall, 174 patients underwent ileocolic anastomosis: KSA, 83 (47.7%) and SSTS, 91 (52.3%). In the KSA group, compared to SSTS, median BMI was lower (24.3 vs. 26.4 kg/m2, p=0.04), median operative time was longer (186 vs. 146 minutes, p<0.001), and patients were more likely to have mesenteric excision (53% vs. 15.4%, p<0.001). There were no significant differences in the short-term postoperative outcomes. After 12 months, 12 (30%) patients in the KSA group and 14 (35%) in the SSTS group developed endoscopic recurrence with a Rutgeerts score ≥i2 (p = 0.81). Compared with the SSTS group, the KS group received more postoperative biologics (65.1% vs. 39.6%, p=0.001) and more frequent medical therapy for perianastomotic recurrence [18/20, 90%] vs. [15/22, 68%]; p=0.14). On multivariable analysis, the KSA (OR 0.09, 95% CI 0.01-0.95, p=0.05) was associated with a lower risk of perianastomotic recurrence requiring surgical and endoscopic intervention. Conclusion We did not observe any statistically significant differences in overall recurrence-free survival between KSA and SSTS. However, the Kono-S anastomosis was independently associated with a decreased rate of endoscopic or surgical intervention for perianastomotic recurrence.

Long-term outcomes following ileocolic resection for Crohn's disease: does earlier elective resection affect disease recurrence rates?

Surgical resection in Crohn's disease is sometimes the only alternative treating disease complications or refractory disease. The implications of early resection on disease course are still debatable. We aimed to assess the influence of preoperative disease duration on long-term postoperative disease course. A retrospective analysis of all Crohn's disease patients who underwent an elective primary ileocolic resection between 2010 and 2021 in a single tertiary medical center. The cohort was divided based on disease duration, Group A (47 patients) had a disease duration shorter than 3 years (median of 1 year) and Group B (139 patients) had a disease duration longer than 3 years (median of 11 years). Surgeries were less complex among Group A as noted by higher rates of laparoscopic assisted procedures (68.1% vs. 45.3%, P = 0.006), shorter surgery duration (134 vs. 167 min, P < 0.0001) less estimated blood loss (72.5 vs. 333 mL, P = 0.016) and faster return of bowel function (3 vs. 4 days, P = 0.011). However, propensity score matching nullified all the differences. Younger age (OR = 0.86, P = 0.004), pre-op steroids (OR = 3.69, P = 0.037) and longer disease duration (OR = 1.18, P = 0.012) were found to be independently significantly associated with severe complications. After a median follow-up time of 71.38 months no significant differences were found between the groups in terms of endoscopic (P = 0.59), or surgical recurrences rates (P = 0.82). The main effect of preoperative short disease duration was noted within the surgical complexity; however, matching suggests confounders as cause of the difference. No significant long-term implication was noted on disease recurrence.

P196 Major variance in scoring of endoscopic recurrence after ileocolic resection for Crohns Disease – a systematic review and meta-analysis

Abstract Background Adequate scoring of endoscopic recurrence in Crohn’s disease patients is of utmost importance, as it is used to diagnose recurrent disease, to predict disease outcomes, to (re-)initiate or change therapy and to monitor its effect. This study aims to assess the variance in endoscopic recurrence in patients after ileocolic resection for Crohn's disease using the most common classification systems, the Rutgeerts (RS) and modified Rutgeerts (mRS) classification. Methods A systematic literature search using MEDLINE, Embase and the Cochrane Library was performed. All RCTs and cohort studies describing endoscopic recurrence after an ileocolic resection for Crohn's disease were included. Main outcome was the range of endoscopic recurrence rates within twelve months postoperatively, defined as RS≥i2 and/or mRS≥i2b. A proportional meta-analysis was performed. Results Seventy-six studies comprising 7751 patients were included. The weighted mean of the endoscopic recurrence rates, defined as either RS≥i2 and/or mRS≥i2b, was 43.99% (95 per cent CI 43.56 – 44.43), ranging from 5.0% – 93.0%, fig 1. For studies reporting endoscopic recurrence defined as ≥i2 and for studies reporting recurrence defined as ≥i2b the weighted means were 44.0% (range 5.0% – 93.0%) and 41.1% (range 19.8% – 62.9%) respectively. Within studies reporting both RS and mRS the weighted means for endoscopic recurrence were 61.3% (range 39.1% – 84.7%) and 40.6% (range 19.8% – 62.0%) respectively. Conclusion This study demonstrates a major variance in scoring endoscopic recurrence after ileocolic resection for Crohn's disease, with the greatest variance when using the original Rutgeerts classification. This suggests a high likelihood of inadequate diagnosis of disease recurrence, with major implications for quality of life and health care consumption. Therefore, there is an important need to improve endoscopic scoring of recurrent disease.

DOP77 Is durable remission achievable after ileocolic resection for Crohn’s disease ? Long-term results of a prospective multicentric cohort study of the GETAID Chirurgie

Abstract Background Most of the patients undergoing bowel resection for Crohn’s disease (CD) develop postoperative recurrence requiring medical treatment intensification or surgery. Is there a subgroup of patients for which surgery allows durable remission? Methods In this retrospective follow-up study, we collected data from 592 patients undergoing ileocolic resection for CD who were included from 2013 to 2015 in a prospective nation-wide cohort of the GETAID Chirurgie group. Patients with follow-up superior to 36 months were included. Primary outcome was durable remission, defined as the absence of endoscopic recurrence (Rutgeerts ≥i2) and/or absence of medical treatment intensification. Uni- and multivariate analyses of the predictive factors for durable remission were carried out. Results Among 268 included patients, 158 (59%) had a B2 stricturing phenotype, 92 (34%) had a B3 penetrating phenotype and 18 (7%) had a non-stricturing non-perforating phenotype (Montreal classification). One hundred and eighty-eight patients (70%) had a primary ileocolic resection. One hundred and sixty-seven patients (66%) had postoperative medical treatment to prevent postoperative recurrence (Table 1). After a median follow-up of 85 (36-104) months, 52 patients (19%) had a durable remission, among which 24 (46%) had no medical treatment and 28 (54%) maintained the same postoperative prophylactic treatment, including anti-TNF therapy in 15 patients (54%) (Table 2). Durable remission rate was significantly increased in B1 phenotype vs B2/B3 (n=7/18 ;39% vs n=45/250; 18%, p=0.030) and in primary ileocolic resection vs redo ileocolic resection (n=43/184 ; 23% vs n=9/80 ; 11%, p=0.023). In multivariate analysis, B1 phenotype was an independent predictive factor for durable remission (OR=3.59, IC95%[1.13-11.37], p=0.030) (Table 3). Conclusion These long-term data obtained from a nation-wide prospective cohort are in line with those of a randomised controlled trial (LIR!C) and show that durable remission is obtained in nearly 40% of CD patients with non-stricturing non-penetrating phenotype operated for CD refractory to medical treatment. This important result should be considered when medical treatment intensification versus surgery is discussed in these patients.

P236 Endoscopic Recurrence or Anastomotic Wound Healing Phenomenon after Ileocolic Resection for Crohn’s Disease: The Challenges of Accurate Endoscopic Scoring

Abstract Background Adequate endoscopic scoring in Crohn’s disease (CD) is crucial, as it dictates the need for initiating postoperative medical therapy and is utilised as outcome parameter in clinical trials. We aimed to observe anastomotic wound healing in relation to endoscopic scoring of both inverted and everted stapled lines in side-to-side anastomoses. Methods Two prospective patient cohorts were included: ileocolic resection (ICR) for CD, and right-sided colon resection for colorectal cancer (CRC). Videos taken during colonoscopy six months postoperatively were evaluated. The SES-CD and modified Rutgeerts score were determined. Primary outcome was the presence of ulcerations in CD patients on both the inverted and everted stapled lines, fig1. Secondary outcomes were the presence of anastomotic ulcerations in CRC patients and the number of cases having ulcerations exclusively at the inverted stapled line. Results Of the 82 patients included in the CD cohort, ulcerations were present in 63/82 (76·8%) at the inverted- versus 1/71 (1·4%) at the everted stapled line. Likewise in the CRC cohort, ulcerations were present in 4/6 (67·7%) at the inverted versus 0/6 (0%) at the everted stapled line. 27% of the 63 patients in the CD cohort had ulcerations exclusively on the inverted stapled line. Conclusion Inverted stapled lines heal with ulcerations, whereas the everted stapled line heal without any ulcerations, both in CD and non-CD patients. The abnormalities at the inverted stapled line might interfere with endoscopic scoring of recurrence, with potentially an impact on patients’ quality of life and on health-care costs if postoperative treatment is initiated incorrectly.

P392 Risk factors for postoperative recurrence after ileocolic resection for Crohn’s Disease: long-term results from a population-based cohort.

Abstract Background Crohn’s disease (CD) patients often require surgical interventions and post operative recurrence is common. Data regarding risk factors for recurrence in representative cohorts are scarce. We assessed the risk-factors of recurrence of CD after ileocolic resection (ICR) in a population based cohort. Methods Patients who underwent a primary or re-resection for ileocolic CD between 2003 and 2017 were included. The primary endpoint was clinical recurrence. The secondary outcome was surgical recurrence. A Cox regression model was used to assess recurrence free survival. Results 289 patients were included of which 120 male (41.5%). Most common indication for ICR was stricturing (B2) disease in 146 (50.5)%), followed by penetrating (B3) disease in 101 (34.9%). Recurrence occurred in 189/289 patients (65.4%) after a median follow up of 2.3 years and surgical recurrence in 22 (7.6%) after median follow up of 4.8 years. Multivariate analysis showed a significant higher chance of clinical recurrence in smokers (HR: 1.659 (95% CI: 1.230; 2.238)) (p&amp;lt;0.05), patients with prior resections (HR: 1.514 (95% CI: 1.014; 2.261)) (p&amp;lt;0.05), perianal involvement (HR: 1.453 (95% CI: 1.033; 2.044)) (p&amp;lt;0.05) and isolated involved proximal resection margin (HR: 1.615 (95% CI: 1.039; 2.509)) (p&amp;lt;0.05). B2 and B3 disease behaviour and post-operative medication was associated with less recurrence, respectively (HR 0.397 (95% CI: 0.253; 0.624)) (p&amp;lt;0.05), (HR 0.443 (95% CI: 0.282; 0.696)), (p&amp;lt;0.05) and (HR: 0.658 (95% CI: 0.473; 0.916)) (p&amp;lt;0.05). Considering surgical recurrence, underweight and overweight BMI and open surgery decreased the chance on recurrence. Conclusion Our study in a population based cohort confirmed risk factors for recurrence consistent with current evidence, but also identifies novel and less frequently found risk factors. Medical therapy reduces the risk for recurrence on a population level. We found an association between involved resection margin and recurrence. Differences between studies may be caused by differences in patient selection or definition of recurrence. Confirmation of this finding in independent representative cohort is necessary. This indicates a need for a standardised scientific database for future prospective research.

Endoscopic Recurrence or Anastomotic Wound Healing Phenomenon after Ileocolic Resection for Crohn's Disease: The Challenges of Accurate Endoscopic Scoring.

Adequate endoscopic scoring in Crohn's disease [CD] is crucial, as it dictates the need for initiating postoperative medical therapy and is utilized as an outcome parameter in clinical trials. Here we aimed to observe anastomotic wound healing in relation to endoscopic scoring of both inverted and everted stapled lines in side-to-side anastomoses. Two prospective patient cohorts were included: ileocolic resection [ICR] for CD, and right-sided colon resection for colorectal cancer [CRC]. Videos taken during colonoscopy 6 months postoperatively were evaluated. The Simplified Endoscopic Activity Score for Crohn's Disease and modified Rutgeerts score were determined. The primary outcome was the presence of ulcerations in CD patients on both the inverted and the everted stapled lines. Secondary outcomes were the presence of anastomotic ulcerations in CRC patients and the number of cases having ulcerations exclusively at the inverted stapled line. Of the 82 patients included in the CD cohort, ulcerations were present in 63/82 [76.8%] at the inverted- vs 1/71 [1.4%] at the everted stapled line. Likewise in the CRC cohort, ulcerations were present in 4/6 [67.7%] at the inverted vs 0/6 [0%] at the everted stapled line. In total, 27% of the 63 patients in the CD cohort had ulcerations exclusively on the inverted stapled line. Inverted stapled lines heal with ulcerations, whereas everted stapled lines heal without any ulcerations, in both CD and non-CD patients. The abnormalities at the inverted stapled line might interfere with endoscopic scoring of recurrence, with potentially an impact on patients' quality of life and on healthcare costs if postoperative treatment is initiated incorrectly.

It is not NOD2 — genetic and clinical risk factors for postoperative complications following ileocolic resection in Crohn’s disease

PurposeTo evaluate the role of the nucleotide oligomerization domain 2 (NOD2) mutation status and other risk factors for the incidence of postoperative complications after ileocolic resection for Crohn’s disease (CD).MethodsData of 138 patients consecutively undergoing ileocolic resection for CD at a tertiary academic referral center were retrospectively analyzed including single nucleotide polymorphism (SNP) data of the NOD2 gene. Uni- and multivariate regression analysis was performed to identify factors associated with increased risk of severe postoperative complications.ResultsFrom 114 patients (83%), the NOD2 mutation status was available. Of these, 60 (53%) had a NOD2 wildtype, whereas eleven (10%) were homozygous for the high risk p.Leu1007fsX1008 (rs2066847) variant. Major postoperative complications occurred in 28 patients (20%). Twenty-seven of these (96%) were intraabdominal septic complications such as anastomotic leakage or abscess. Male gender (P = 0.029; OR 3.052, the duration of CD (time [months] from initial diagnosis of CD to surgery; P = 0.001; OR 1.009), previous abdominal surgery for CD (P = 0.017; OR 3.49), and the presence of enteric fistulas (P = 0.023; OR 3.21) were identified as independent risk factors for major postoperative complications. Homozygosity for the NOD2 high-risk variant p.Leu1007fsX1008 did not show increased postoperative morbidity in the short and long-term outcome.ConclusionsWe could detect independent risk factors for major postoperative complications after ileocolic resection for Crohn’s disease. However, patients with the high-risk variant p.Leu1007fsX1008 of the NOD2 gene did not show increased postoperative morbidity.

Factors associated with stoma formation in ileocolic resection for Crohn's disease and the development of a predictive scoring system.

The likelihood of a stoma following ileocolic resection (ICR) for Crohn's disease (CD) is an important consideration. This study aims to identify the factors associated with an increased likelihood of a stoma and develop a predictive scoring system (SS). Patient data were collected from St. Marks Hospital, London, UK and Humanitas Clinical and Research Center, Milan, Italy, on all patients who underwent an ICR for CD from 2005 to 2017. A logistic regression analysis was used for multivariate analysis. The SS was developed from the logistic regression model. The performance of the SS was evaluated using receiver operating characteristics area under the curve (AUROC). A total of 628 surgeries were included in the analysis. Sixty-nine surgeries were excluded due to missing data. The remaining 559 were divided into two cohorts for the scoring system's development (n = 434) and validation (n = 125). The regression model was statistically significant (p < 0.0001). The statistically significant independent variables included sex, preoperative albumin and haemoglobin levels, surgical access and simultaneous colonic resection. The AUROC for the development and validation cohorts were 0.803 and 0.905, respectively (p < 0.0001). Youden's index suggested the cut-off score of - 95.9, with a sensitivity of 87.6% and a specificity of 62.9%. Male sex, low preoperative albumin, anaemia, laparoscopic conversion and simultaneous colonic resection were associated with an increased likelihood of requiring a stoma and were used to develop an SS. The calculator is available online at https://rebrand.ly/CrohnsStoma .

Endoscopic Evaluation at 1 Month After Ileocolic Resection for Crohn's Disease Predicts Future Postoperative Recurrence and Is Safe.

Endoscopy remains the gold standard for evaluating postoperative recurrence in Crohn's disease. Timely therapy adjustment according to endoscopic findings can improve long-term outcomes. We aimed to determine the characteristics, clinical values, and safety of the endoscopic evaluation at 1 month after surgery. This was a prospective observational study. This study was conducted in a tertiary referral hospital. Patients with Crohn's disease undergoing ileocolic resection between January 2016 and November 2018 were included. The first postoperative ileocolonoscopy was performed at 4-5 weeks after surgery. The primary outcome was postoperative recurrence within 12 months after surgery. Univariate and multivariate analyses were performed to identify risk factors. Among 84 ileocolonoscopies at 4-5 weeks, no endoscopic complication occurred. The main endoscopic findings at the first evaluation were anastomotic circumferential ulcers (10, 11.9%), anastomotic scattered ulcers (35, 41.7%), ulcers in the neoterminal ileum (16, 19.0%), edema in anastomosis (50, 59.5%), mild narrowing in anastomosis (7, 8.3%), and mild narrowing in neoterminal ileum (3, 3.6%). Anastomotic scattered ulcers were associated with future postoperative recurrence (OR, 2.532 (95% CI, 1.02-6.32), p = 0.046). Fecal calprotectin >150 ug/g on postoperative day 14 could predict anastomotic scattered ulcers (OR' 2.91 (95% CI, 1.31-7.47), p = 0.027). The modified Rutgeerts score was used to define endoscopic findings: i0, 37 (44.0%); i1, 4 (4.8%); i2a, 29 (34.5%); i2b, 11 (13.1%); i3, 0; i4, 3 (3.6%). Score ≥i2a were associated with future postoperative recurrence (OR, 3.17 (95% CI, 1.22-8.27), p = 0.018). No factor was associated with a Rutgeerts score of ≥i2a at the first endoscopic evaluation. This was a single-center study with a small cohort of patients. Endoscopic evaluation at 1 month after surgery in CD was safe. Anastomotic scattered ulcers occurred in nearly half of patients and were associated with future postoperative recurrence. See Video Abstract at http://links.lww.com/DCR/B760.LA EVALUACIÓN ENDOSCÓPICA A UN MES DESPUÉS DE LA RESECCIÓN ILEOCÓLICA PARA LA ENFERMEDAD DE CROHN, PREDICE FUTURA RECURRENCIA POSOPERATORIA Y ES SEGURAANTECEDENTES:La endoscopia sigue siendo el estándar de oro para evaluar la recurrencia posoperatoria en la enfermedad de Crohn (EC). El ajuste oportuno en la terapia de acuerdo con los hallazgos endoscópicos, puede mejorar los resultados a largo plazo.OBJETIVO:Determinar las características, valores clínicos y seguridad de la evaluación endoscópica, al mes de la cirugía.DISEÑO:Estudio observacional prospectivo.ENTORNO CLINICO:El estudio se llevó a cabo en un hospital de referencia terciario.PACIENTES:Se incluyeron pacientes con EC sometidos a resección ileocólica entre enero de 2016 y noviembre de 2018.INTERVENCIONES:La primera ileocolonoscopia posoperatoria se realizó a las 4-5 semanas posteriores a la cirugía.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la recurrencia posoperatoria dentro de los 12 meses posteriores a la cirugía. Se realizaron análisis univariados y multivariados para identificar factores de riesgo.RESULTADOS:Entre 84 ileocolonoscopias a las 4-5 semanas, no ocurrió ninguna complicación endoscópica. Los principales hallazgos endoscópicos en la primera evaluación, fueron úlceras anastomóticas circunferenciales (10, 11,9%), úlceras anastomóticas dispersas (35, 41,7%), úlceras en el íleon neo-terminal (16, 19,0%), edema en la anastomosis (50, 59,5%), estrechamiento leve en la anastomosis (7, 8,3%) y estrechamiento leve en el íleon neo-terminal (3, 3,6%). Las úlceras anastomóticas dispersas se asociaron con recurrencia posoperatoria futura (OR, 2,532 (95% CI, 1,02-6,32), p = 0,046). La calprotectina fecal en el post d 14 > 150 ug / g podría predecir úlceras anastomóticas dispersas (OR' 2,91 (95% CI, 1,31-7,47), p = 0,027). Se utilizó la puntuación de Rutgeerts modificada para definir los hallazgos endoscópicos: i0, 37 (44,0%); i1, 4 (4,8%); i2a, 29 (34,5%); i2b, 11 (13,1%); i3, 0; i4, 3 (3,6%). La puntuación ≥i2a se asoció con recurrencia posoperatoria futura (OR, 3,17 (95% CI, 1,22-8,27), p = 0,018). Ningún factor se asoció con ≥i2a en la primera endoscopia.LIMITACIONES:Estudio de un solo centro con una pequeña cohorte de pacientes.CONCLUSIONES:La evaluación endoscópica al mes de la cirugía en EC, fue segura. Se produjeron úlceras anastomóticas dispersas en casi la mitad de los pacientes y se asociaron con una futura recurrencia posoperatoria. Consulte Video Resumen en http://links.lww.com/DCR/B760. (Traducción - Dr. Fidel Ruiz Healy).

P194 A modified Rutgeerts score of i2a after ileocolic resection for Crohn’s Disease: endoscopic recurrence or anastomotic healing?

Abstract Background The reliability and reproducibility of scoring endoscopic recurrence is of utmost importance because it generally determines initiating postoperative medical therapy and it is used as outcome parameter in clinical trials. Variability in endoscopic scoring may result in inappropriate therapeutic decisions and study conclusions. It is hypothesised that different types of anastomoses have an influence on scoring endoscopic recurrence using the Rutgeerts’ score. The aim of this study is to analyse to what extent the ulcerations are determined by the type of anastomosis and how it interferes with the scoring of Crohn’s recurrence. Methods This is a retrospective review of endoscopy videos to re-assess endoscopic recurrence. All videotapes of the ileocolonoscopy were blinded and scored by a trained gastroenterologist (MD) and a surgeon (WB). Videos were excluded if the quality of the video was low or if the anastomosis was not visualised properly. The primary outcome is the presence of ulcerations six months after surgery, on individual parts of the anastomosis: inverting stapled anastomosis (side to side conjunction) and everting type of junction (transection ends). In the latter group, at least one site – colon, ileum or both – was scored. Results Of 99 available endoscopy videos, eighty-nine eligible patients were included in this retrospective study for analysis. The inverting and everting stapled anastomosis were scored individually using the SES-CD. A SES-CD of zero was found in 21/89 (23.6%) of the inverting anastomoses versus 74/75 (98.67%) in the everting anastomoses. Conclusion This study demonstrated a significant difference in wound healing of the inverting anastomosis versus the everting anastomosis. Inverting anastomoses show ulcerations and a circular scar long after surgery irrespective of the presence of ulcerations of terminal ileum. A normal wound healing phenomena might mistakenly be seen for recurrent Crohns’ disease. Everting anastomosis, on the contrary, heal without residue.

P416 Addition of oral antibiotics to mechanical bowel preparation significantly improves anastomotic healing after ileocolic resection for Crohn’s disease

Abstract Background Addition of oral antibiotics (OA) to mechanical bowel preparation (MBP) is thought to reduce postoperative morbidity compared to MBP alone. However, data supporting this concept in Crohn’s disease patients undergoing ileocolic resection do not exist. Methods Starting, 2016, all ileocolic resections were performed after preoperative MBP combined with OA consisting of two separate dosages of Metronidazole/Neomycine or Metronidazol/Paramomycine. These patients were compared to previous controls undergoing ileocolic resection after mere MBP (1992–2005). Between, 2005 and, 2016, surgeries were performed without preoperative MBP. Patients undergoing an ileocolic resection without construction of anastomosis (i.e., two staged resection) and patients not receiving MBP were excluded from the study. „Anastomotic complications“ were defined as anastomotic leakage, presence of abscess or peritonitis in direct proximity to anastomosis. Results 312 patients underwent ileocolic resections with construction of an anastomosis:, 159 after MBP only and, 153 after preoperative MBP+OA. Patients in MBP+OA group were older (39 y. vs., 35 y., p=0.001), had penetrating disease less frequently (50% vs., 69%, p=0.001), were on biologicals more frequently (31% vs., 1%, p&amp;lt;0.001), on steroids less frequently (12% vs., 59%, p&amp;lt;0.001), underwent laparoscopic surgery more often (80% vs., 15%, p&amp;lt;0.001), and received preoperative parenteral nutrition more often (16% vs., 7%, p=0.033). Patients receiving OA were not able to complete MBP more often (19% vs., 9%, p=0.009). By the multivariate analysis, addition of OA to MBP was associated with a significant reduction of anastomotic complication rate (3% vs., 11%, Hazard ratio, 0.24, p=0.036). Weight loss and steroids were associated with an increased anastomotic morbidity. Conclusion Oral antibiotics added to MBP further improve the anastomotic healing in Crohn’s disease patients undergoing ileocolic resection, although the study has demonstrated an apparent time bias. Further research is needed to clarify whether OA without MBP are as protective as MBP+OA.

Preoperative Anti-TNF Therapy is Associated with a Shorter Length of Resected Bowel in Patients Undergoing Ileocolic Resection for Crohn’s Disease

Background Massive or repeated intestinal resections for Crohn’s disease (CD) could lead to disabling consequences. The present study aimed to assess the effect of preoperative anti-TNF therapy on the length of resected bowel and identify risk factors for postoperative morbidity following ileocolic resection for CD. Methods Patients undergoing elective ileocolic resection for CD were included prospectively. Medical variables including demographics, Montréal classification, preoperative treatment, surgical details and 30-day postoperative morbidity were collected. Potential impact of preoperative anti-TNF treatment on length of ileocolic specimen and risk factors for postoperative morbidity were investigated. Results One hundred and eight-four patients were included in this study, and 66 (35.9%) of them received anti-TNF agents within 8 weeks prior to surgery. Primary anastomosis was performed in 145 patients (78.8%). The mean length of resected intestine was 10 cm shorter in subjects receiving preoperative anti-TNF treatment than those without preoperative anti-TNF therapy (P < 0.001). The rates of postoperative overall, infectious and intra-abdominal septic morbidity were 29.9%, 19.0% and 7.6%, respectively. In multivariate analysis, anti-TNF therapy < 8 weeks before surgery was independently associated with a shorter length of resected bowel but didn’t increase overall and septic complications, while systemic steroids use within 8 weeks prior to surgery independently increased overall complications and intra-abdominal sepsis. Conclusions Preoperative anti-TNF therapy was associated with a shorter length of resected bowel but not the overall and septic postoperative complications in ileocolic resection for CD. Weaning off systemic steroids before surgery may improve postoperative outcomes in patients with CD.

Mesenteric Excision and Exclusion for Ileocolic Crohn's Disease: Feasibility and Safety of an Innovative, Combined Surgical Approach With Extended Mesenteric Excision and Kono-S Anastomosis.

Ileocolic resection for Crohn's disease traditionally does not include a high ligation of the ileocolic pedicle, and most commonly is performed with a stapled side-to-side ileocolic anastomosis. The mesentery has recently been implicated in the pathophysiology of Crohn's disease. Two techniques have been developed and are associated with reduced postoperative recurrence: the Kono-S anastomosis that excludes diseased mesentery and extended mesenteric excision that resects diseased mesentery. We aimed to assess the technical feasibility and safety of a novel combination of techniques: mesenteric excision and exclusion. This initial report is a single-center descriptive study of consecutive adults who underwent mesenteric excision and exclusion for primary or recurrent ileocolic Crohn's disease from September 2020 to June 2021. Medication exposure and endoscopic balloon dilation before surgery were recorded. Phenotype was classified using the Montreal Classification. Thirty-day outcomes were reported. A video of the mesenteric excision and exclusion including the Kono-S anastomosis is presented. Twenty-two patients with ileocolic Crohn's disease underwent mesenteric excision and exclusion: 100% had strictures, 59% had fistulas, 81% were on biologics, and 27% had previous ileocolic resection(s). Seventy-two percent underwent laparoscopic procedures, a mesenteric defect was closed in 86%, omental flaps were fashioned in 77%, and 3 patients were diverted. Median operative time was 175 minutes. Median postoperative stay was 4 days. At 30 days, there were 2 readmissions for reintervention: 1 seton placement and 1 percutaneous drainage of a sterile collection. There were no cases of intra-abdominal sepsis or anastomotic leak. Mesenteric excision and exclusion represents an innovative, progressive, and promising approach that appears to be highly feasible and safe. Further study is warranted to determine if mesenteric excision and exclusion is associated with reduced postoperative recurrence of ileocolic Crohn's disease.

Localization of recurrent lesions following ileocolic resection for Crohn\u2019s disease

BackgroundCrohn’s disease (CD) recurrence can occur not only at the site of anastomosis but also elsewhere in the bowel following an ileocolic resection (ICR) procedure. The aims of the present study were to assess long-term outcomes of a primary ICR procedure for CD in consecutive patients and examine the location of the reoperation causative lesion.MethodsWe examined cases of surgery with ICR initially performed at our institution. Those with simultaneous multiple bowel resection or bowel resection with strictureplasty were excluded.ResultsA total of 169 patients who underwent ICR due to CD were enrolled. The median follow-up period was 12.6 years (range 4–27 years). A reoperation was needed in 45 (26.6%), of whom 14 had lesions causative of the reoperation at other than the anastomotic site. The most common causative lesion location was in the colon rather than the oral side of the small intestine. Furthermore, we investigated the relationship between presence of residual lesions following the initial surgery and lesions causative of reoperation. In the group without residual disease (n = 31), 29.0% (n = 9) had non-anastomotic lesions involved in indications for reoperation, while that was 35.7% (n = 5) in the group with residual disease (n = 14).ConclusionsAnastomotic site lesion is not the only causative factor for reoperation following ICR. Regular examinations and applicable treatment with awareness that the cause of reoperation is not limited to the site of anastomosis are important in these cases.

Risk factors for symptomatic anastomotic postoperative recurrence following ileo-colic resection in Crohn's disease.

Crohn's disease is a chronic inflammatory bowel disease characterized by alternating periods of exacerbation and remission. Surgical resection is not curative and postoperative recurrence (POR) remains a challenge in these patients. The aim of this study was to identify clinical variables that influence the risk of symptomatic anastomotic POR in patients with ileo-colonic Crohn's disease. A retrospective study of Crohn's disease patients who had undergone ileo-colic resection between January 2014 and December 2018 was performed. For each patient, data including demographic information, Crohn's disease clinical setting, preoperative radiological data, operative and histological data, pre- and postoperative medication history and postoperative clinical course, including recurrence of disease, were extracted. Symptomatic anastomotic POR was defined as symptoms of Crohn's disease in the presence of confirmed anastomotic POR (endoscopic and/or radiological POR). For the study period, 104 patients were eligible and included for analysis. The cumulative probability of symptomatic anastomotic POR was 14%, 30%, 42%, 50% and 50% at 1, 2, 3, 4 and 5years, respectively. Two clinical variables on multivariate analysis were associated with increased risk of symptomatic anastomotic POR, namely age <17years at diagnosis [hazard ratio (HR) 2.17, p=0.019] and gastrointestinal involvement (extent) >30cm (HR 1.85, p=0.048). This study describes the natural history of POR after ileo-colic resection for Crohn's disease, as defined by endoscopic, radiological and clinical outcomes. Age <17years at diagnosis and gastrointestinal involvement (extent) >30cm were independent risk factors for symptomatic anastomotic POR.

AB079. Mesenteric resection is safe and feasible for patients undergoing ileocolic resection for Crohn’s disease

AB079. Mesenteric resection is safe and feasible for patients undergoing ileocolic resection for Crohn’s disease

AntiTNF α: Risk Factor of Major Complications Following Ileocolic Resection for Crohn's Disease

Introduction: The aim of this study was to determine the risk factors of complications in the era of anti-tumor necrosis factor. Methods: This was a single-center retrospective study covering the period 1999 to 2015 of patients who underwent a first ileocolic resection for Crohn's disease. We evaluated the impact of preoperative characteristics and operative data on serious complications within 90 days after surgery. Results: 146 patients were included. Post-operative morbidity was 43.8 % with 21 serious complications (14.4%). A univariate analysis, anti TNF in the 3 months before surgery (p= 0.0007), anti TNF and corticosteroid combination (p = 0.006), and operating time upper than 150 minutes (p= 0.01),were associated with the occurrence of a serious complication. In multivariate analysis, anti TNF (OR = 4.21; 95% CI 1.23 to 16.87; p= 0.02) and conversion (OR = 7.95; 95% CI = 1,68- 44.89; p= 0.009) were risk factors of serious complications. Conclusion: The use of anti-TNF within 3 months before surgery and conversion during laparoscopy are risk factors of serious complications after ileocolic resection for Crohn's disease.