Intestinal Resection In Patients Research Articles

Correlation between white blood cell count and intestinal resection in patients with acute mesenteric vein thrombosis

ObjectiveAcute mesenteric vein thrombosis (AMVT) is an acute abdominal disease with onset, rapid progression, and extensive intestinal necrosis that requires immediate surgical resection. The purpose of this study was to determine the risk factors for nosocomial intestinal resection in patients with AMVT.MethodsWe retrospectively analysed 64 patients with AMVT diagnosed by CTA at the Affiliated Hospital of Kunming University of Science and Technology from January 2013 to December 2021. We compared patients who underwent intestinal resection (42 patients) with those who did not undergo intestinal resection (22 patients). The area under the ROC curve was evaluated, and a forest map was drawn.ResultsAmong the 64 patients, 6 (9.38%) had a fever, 60 (93.75%) had abdominal pain, 9 (14.06%) had a history of diabetes, 8 (12.5%) had a history of deep vein thrombosis (DVT), and 25 (39.06%) had ascites suggested by B ultrasound or CT after admission. The mean age of all patients was 49.86 ± 16.25 years. The mean age of the patients in the enterectomy group was 47.71 ± 16.20 years. The mean age of the patients in the conservative treatment group (without enterectomy) was 53.95 ± 15.90 years. In the univariate analysis, there were statistically significant differences in leukocyte count (P = 0.003), neutrophil count (P = 0.001), AST (P = 0.048), total bilirubin (P = 0.047), fibrinogen (P = 0.022) and DD2 (P = 0.024) between the two groups. The multivariate logistic regression analysis showed that admission white blood cell count (OR = 1.153, 95% CI: 1.039–1.280, P = 0.007) was an independent risk factor for intestinal resection in patients with AMVT. The ROC curve showed that the white blood cell count (AUC = 0.759 95% CI: 0.620–0.897; P = 0.001; optimal threshold: 7.815; sensitivity: 0.881; specificity: 0.636) had good predictive value for emergency enterectomy for AMVT.ConclusionsAmong patients with AMVT, patients with a higher white blood cell count at admission were more likely to have intestinal necrosis and require emergency enterectomy. This study is helpful for clinicians to accurately determine whether emergency intestinal resection is needed in patients with AMVT after admission, prevent further intestinal necrosis, and improve the prognosis of patients.

P457 Small bowel involvement proximal to the terminal ileum is a major risk factor for intestinal resection in patients with small bowel Crohn’s disease

Abstract Background The current Montreal classification categorizes Crohn's disease (CD) with small bowel involvement into two groups: L1 and L3. The study aimed to investigate the significance of small bowel involvement proximal to the terminal ileum as a significant risk factor for intestinal resection. Methods We conducted a retrospective review of the medical records of Crohn's disease patients diagnosed between January 2001 and December 2020 at Seoul St. Mary's Hospital, St. Vincent Hospital, and Eunpyeong St. Mary's Hospital. The extent of small bowel involvement was independently assessed by two experienced gastrointestinal radiologists using conventional CT, CT enterography, or MR enterography at the time of diagnosis. The terminal ileum was defined as the distal ileal segment within 10 cm from the ileocecal valve and the jejunum was defined as the proximal 1/2 of the small intestine beyond the ligament of Treitz. Radiologic disease activity and fibrostenosis at the time of diagnosis were also scored as 0, 1, and 2 using Maglinte classification, respectively. Results Out of 617 CD patients, 346 were included in the study, while 271 were excluded due to radiologic noninvolvement of the small bowel, inadequate or missing radiologic data, initial diagnosis made at another institution, or diagnosis through surgery. Median age at diagnosis was 24 years (range 10-76) and 250 (72.3%) were male. The median follow-up duration was 53 months (4-201). During the follow-up period, 43 patients (12.4%) underwent intestinal resection. Small bowel involvement proximal to the terminal ileum was significantly associated with a higher cumulative risk of intestinal resection (15.4% vs. 3.5%, P=0.006). Neither jejunal involvement or colonic involvement (L3 vs. L1) showed a significant association with cumulative risk of intestinal resection (16.0% vs. 11.1%, P=0.222; 12.4% vs. 12.4%, P=0.773). Radiologic disease activity and fibrostenotic score at the time of diagnosis were significantly associated with the cumulative risk of intestinal resection, respectively (0% vs. 4.4% vs. 19.7%, P<0.001; 8.5% vs. 16.7% vs. 28.2%, P<0.001). Conclusion Small bowel involvement proximal to the terminal ileum was a major risk factor for requiring intestinal resection in patients with small bowel CD, while jejunal involvement was not. These findings suggest a need for subclassifying small bowel CD.

Neutrophil-to-lymphocyte ratio as a predictor of intestinal resection in incarcerated inguinal hernias

Inguinal hernia is defined as a projection of an organ through the inguinal canal. This can be incarcerated as a consequence of continuous inflammation of the hernial sac, which will prevent its return, causing damage to the venous and lymphatic return of the viscera. The neutrophil-to-lymphocyte ratio (NLR) is an easily accessible inflammatory biomarker obtained from blood cell counts. Therefore, the objective was to determine if the NLR is useful as a predictor of intestinal resection in incarcerated inguinal hernias. An observational, analytical, diagnostic test and retrospective study was carried out in a hospital in northern Peru from January 2013 to August 2019 in the Department of General Surgery and Emergency Surgery and Critical Care. Patients diagnosed with unilateral inguinal hernia with intestinal obstruction were included. For the relationship between the event and the exposure, it was analyzed using Chi square (χ2) and T-Student. The sensitivity, specificity, positive predictive value, negative predictive value of the NLR as well as the area under the ROC curve were found to determine the predictive accuracy. 161 patients with incarcerated inguinal hernia were studied: group I (20 patients with intestinal resection) and group II (141 patients without intestinal resection). The mean age in groups I and II were 69±16 and 60±17 years (p<0.05); the frequency in males was 70% in group I and 76% in group II (p>0.05). Intestinal obstruction and duration of incarceration >24 hours and the platelet-to-lymphocyte ratio demonstrated significant differences. With respect to NLR taking a cut-off point ≥6.5, a sensitivity of 75%, a specificity of 93.62%, a positive predictive value of 62.5% and a negative predictive value of 96.35% were observed; In addition, when analyzing with the ROC curve, a value of 5.14 was obtained as a predictor of intestinal resection with a sensitivity of 90% and a specificity of 84.4% (p<0.001). Therefore, the NLR >5.14 predicts intestinal resection in patients with incarcerated inguinal hernias with an area under the curve of 0.92 at the Belen Hospital of Trujillo. The neutrophil-to-lymphocyte ratio is useful for predicting intestinal resection with a diagnostic accuracy of 92%.

Percutaneous Drainage vs. Surgery as Definitive Treatment for Anastomotic Leak after Intestinal Resection in Patients with Crohn's Disease.

Anastomotic leak (AL) remains one of the most relevant complications after intestinal resection for Crohn's disease (CD). While surgery has always been considered the standard treatment for perianastomotic collection, percutaneous drainage (PD) has been proposed as a potential alternative. Retrospective study in consecutive patients treated with either PD or surgery for AL after intestinal resection for CD between 2004 and 2022. AL was defined as a perianastomotic fluid collection confirmed by radiological findings. Patients with generalized peritonitis or clinical instability were excluded. To compare the success rate of PD vs. surgery. Secondary aims: To compare the outcomes at 90 days after the procedures; to identify the variables associated with the indication for PD. A total of 47 patients were included, of which 25 (53%) underwent PD and 22 (47%) surgery. The success rate was 84% in the PD and 95% in the surgery group (p = 0.20). There were no significant differences between the PD and surgery group in postoperative medical and surgical complications, discharge, readmission or reoperation rates at 90 days. PD was more likely to be performed in patients with later diagnosis of AL (OR 1.25, 95% CI 1.03-1.53, p = 0.027), undergoing ileo-colic anastomosis alone (OR 3.72, 95% CI 2.29-12.45, p = 0.034) and treated after 2016 (OR 6.36, 95% CI 1.04-39.03, p = 0.046). The present study suggests that PD is a safe and effective procedure to treat anastomotic leak and perianastomotic collection in CD patients. PD should be indicated in all eligible patients as an effective alternative to surgery.

P639 Percutaneous drainage vs surgery as definitive treatment for anastomotic leak after intestinal resection in patients with Crohn’s disease.

Abstract Background Anastomotic leak remains one of the most relevant complications after intestinal resection for Crohn’s disease (CD). While surgery has always been considered the standard treatment for perianastomotic abscess or collection, percutaneous drainage (PD) has been proposed as a potential alternative. The aim of this study was therefore to compare the success rate of percutaneous drainage with that of surgery for the management of anastomotic leak in CD patients. Methods Retrospective, single-centre study including all consecutive patients who were diagnosed with an anastomotic leak as a complication of intestinal resection for CD between 2004 and 2022. Patients requiring emergency surgery due to generalised peritonitis or clinical instability were excluded. Anastomotic leak was defined as a perianastomotic fluid collection confirmed by radiological findings within 30 days from surgery. Patients underwent either PD or surgery as a primary treatment for the complication. The success after PD was defined as the removal of the drainage with clinical and radiological resolution of the complication. The need for further surgical treatment was considered as a failure in both groups. Primary aim: to compare the success rate of PD vs surgery. Secondary aims: to compare the outcomes at 90 days after the procedures; to identify the variables associated with the indication to PD. Results Among the 47 patients included, 25 (53%) underwent PD and 22 (47%) surgery. Table 1 shows the outcomes by the procedure. Success rate was 84% in PD and 95% in surgery group (p=0.20). The median time to success was 14 days after PD (drainage removal) and 12.5 days after surgery (discharge) (p=0.92). Similar rates of post-procedure medical (12% vs 18%, p=0.55) and surgical (24% vs 36%, p=0.62) complications were shown. An ileostomy was required in 91% of surgery cases. At 90 days, similar rates of discharges (100% vs 95%, p=0.28), readmissions (8% vs 0%, p=0.18) and reoperations (16% vs 9%, p=0.48) were observed between PD and surgery cases, respectively. In the multivariate analysis (Table 2), PD was more likely to be performed in patients whose anastomotic leak was diagnosed later after surgery (OR 1.25, 95%CI 1.03-1.53, p=0.027), in those who underwent an ileo-colic anastomosis alone (OR 3.72, 95%CI 2.29-12.45, p=0.034) and in those who were treated after 2016 (OR 6.36, 95%CI 1.04-39.03, p=0.046). Conclusion The present study confirms that PD is a safe and effective procedure to treat anastomotic leak and perianastomotic abscess in CD patients. Surgery, in particular, is associated with a high risk of stoma formation, which would require a subsequent operation. PD should be indicated in all eligible patients as an effective alternative to surgery.

S39 Use of Electronic Cigarettes in Inflammatory Bowel Disease: A Pilot Study

Background: Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of the gastrointestinal tract likely involving both a genetic predisposition and environmental triggers. Cigarette smoking (CS) has well established links to IBD, as current and former use are risk factors for Crohn’s Disease (CD) and Ulcerative Colitis (UC) respectively. CS may result in increased use of glucocorticoids, immunosuppression and intestinal resection in patients with CD. Nicotine free e-cigarettes can induce gastrointestinal mucosal inflammation, impair the gut mucosal barrier and increase expression of pro-inflammatory cytokines. Data describing the use of e-cigarettes in IBD patients in the US is lacking. We conducted pilot study to determine prevalence and patterns of e-cigarette use in a large academic IBD practice. Methods: This was an IRB-approved study of adult patients with a confirmed diagnosis of IBD. Enrollment occurred in one of 2 arms: (1) MyChart Arm and (2) In-Person Arm. In Arm #1, a query of the electronic medical record (EMR) was performed of all IBD patients (using ICD-10 codes) with a clinic visit between 11/1/2020–10/31/2021. Using the MyChart research functionality within the EMR, eligible patients were directly contacted with a standardized recruitment message. Upon confirming interest, a personalized survey link was created via RedCap (research electronic data capture) and distributed to the patient via e-mail. In-person enrollment (Arm #2) was introduced in August of 2022. Eligible patients were approached by study staff during an existing IBD-related clinic visit. If interested, patients were provided a study information letter and a paper version of the survey to complete. Resulting data was then entered into the RedCap database. Survey questions elicited information regarding: (1) patient demographics, (2) description of current and former use of traditional tobacco products and of e-cigarettes, (3) duration and frequency of use, (4) product preference (5) perception of risk of e-cigarette use, and (6) interest in cessation. Results: A total of 62 patients completed the survey. The majority of our study population was female (n = 41/62; 66.1%), with a mean age of 39.3. Most patients reported a diagnosis of CD (n = 33/62; 53.2%). Approximately 2-thirds of respondents indicated they were “never” cigarette smokers (n = 41/62; 66.1%), and current use of traditional cigarettes was reported at 8.1% (5/62). E-cigarette use (former or current) was reported in 21.7% of patients (n = 13/60), with most beginning as adults (n = 12/13; 92.4%), and using multiple times per day (n = 10/13; 76.9%). Of those reporting e-cigarette use, the majority described their reason for use as “an attempt to quit use of a traditional tobacco product” (n = 7/13; 53.8%). Additionally, of those reporting e-cigarette use, majority considered e-cigarette use to be “less harmful” or “about the same” level of risk compared to CS (12/13; 92.3%). Conclusion(s): This pilot study establishes that e-cigarette use is prevalent in our large volume IBD academic practice, and may in fact be higher than cigarette smoking or other traditional tobacco products. A follow-up project is planned to evaluate implications of e-cigarette use on IBD-related disease outcomes.

P570 Prevalence and risk factors for intestinal resection in patients with Crohn’s disease in a Greek referral center

Abstract Background Nearly half of patients with Crohn’s disease (CD) require any kind of surgical resection within 10 years after diagnosis and about one third of them need an additional second intervention within the next decade. We aimed to investigate the prevalence and risk factors for intestinal resection in Greek patients with CD. Methods Consecutive CD patients with complete follow up data, recorded prospectively in a registry of a tertiary university hospital from 2011–2021, were studied retrospectively. All patients with a history of at least one bowel resection for luminal disease were enrolled. Surgeries for perianal disease, fistulae or other complications were excluded. At the same time, the role of potential risk factors for surgical intervention was analyzed. Results Out of a total of 372 CD patients recorded in the database, 85 patients (23%) with a history of 96 surgical resections were identified. Sixty one percent were male, with a mean (±SD) age of 48.5 (±15.3) years, median (IQR) age at disease diagnosis 25.5 (21–37) years, 39% smokers, L1 49%, L2 11%, L3 40%, B2 57% and B3 37%. Median (IQR) time from diagnosis to first surgical resection was 58 (8.3–120.8) months, while in 17% the diagnosis was made with the surgery. Half of the patients (52%) were operated due to no response to treatment, presenting with ileus or stricture formation, whereas other causes for operation were perforation ± abscess (24%) and dysplasia (4%) [20% cause not specified in files]. Fifty three percent were naïve to biologic treatment prior to surgery and needed resection sooner that those experienced to biologics [median (IQR) time from diagnosis to surgery 12 (0–72) vs 88 (46–172) months, p&amp;lt;0.0001]. A second surgery became necessary in 11 patients (13%) due to disease recurrence after a mean (±SD) time of 152 (±117) months after the first, whereas only one needed a third one. In the univariate analysis bowel resection was associated with younger age at diagnosis (p&amp;lt;0.0001), shorted disease duration (p&amp;lt;0.0001), structural and fistulizing phenotype (p&amp;lt;0.001) and smoking (p=0.0017). All associations remained significant also in the multivariate analysis (Table 1). Conclusion One out of four patients in our cohort needed bowel resection for their luminal CD with younger age at diagnosis, shorter disease duration, structuring/fistulizing phenotype and smoking being identified as possible risk factors.

A new clinical severity score for the management of acute small bowel obstruction

Abstract Objective Small bowel obstruction (SBO) is a common hospital admission diagnosis. Identification of patients who will require a surgical resection because of a non-viable small bowel remains a challenge. We aimed to identify risk factors for intestinal resection in patients with SBO and to develop a practical clinical score designed to guide surgical vs. conservative management. Methods We performed a prospective cohort study and included all patients admitted for an acute SBO between 2007 and 2016 in our center. Patients were divided in three categories: conservative management, surgical treatment with or without bowel resection. Clinical variables were assessed and compared between groups. Logistic regression models were used to identify the best predictors. Results 604 patients were included in this study. 438 (73%) had surgery of which 127 (21%) had small bowel resection. 166 (27%) patients were treated conservatively. Among 13 clinical variables, univariate and multivariate logistic regression models identified 8 variables with a strong association with small bowel resection: age ≥70 years, a first episode of SBO, absence of bowel movement for ≥3 days, abdominal guarding, C-reactive protein ≥50, and 3 signs on abdominal CT-scan, namely, small bowel transition point, lack of small bowel contrast enhancement, and the presence of &amp;gt; 500 mL of intra-abdominal fluid. Each variable was given one point. We observed that 71-100% of patients with ≥4 points required a surgical resection. Sensitivity and specificity of this score were 65% and 88%, respectively and the area under the curve (AUC) was 0.84 (95% CI 0.80-0.89). Additionally, we propose two variants of the 8-tem score: a 7-item score excluding the lack of contrast enhancement, specifically designed for patient with contrast allergies or renal insufficiency, and a simplified 4-item score leaving age, guarding, transition zone on CT-scan, and the presence of 500 mL of fluid on CT scan. Both scores showed similar performances compared to the 8-item score with an AUC of 0.83 and 0.80 for the 7- and 4-item scores, respectively. Conclusion We developed a practical clinical severity score designed to tailor management of patients presenting with a SBO. A score of ≥ 4 points indicates the need for surgical exploration given the high likelihood of small bowel ischemia in these patients.

P598 Previous Intestinal Resection Is Associated with Postoperative Complications in Crohn’s Disease: A Cohort Study

Abstract Background To assess the influence of a previous intestinal resection on postoperative complications for Crohn’s disease (CD). Methods Data on patients with CD undergoing surgery in our department from January 2016 through December 2019 were retrospectively reviewed. Information collected included demographic details, surgical data, and postoperative outcome. A cross- sectional study design was employed. Associations between postoperative complications and preoperative clinical indicators were further analyzed. Results Of the 129 patients with CD studied, 62 patients (48.06%) underwent previous resection. These patients were more likely to be older (P=0:031), have longer disease duration (P=0:025), use less 5-aminosalicylic acid/sulfasalazine preoperatively (P = 0:013), have lower body mass index (P = 0:003), and have a higher American Society of Anesthesiologists (ASA) Physical Status Classification System score (P = 0:043). Patients who had previous surgery had a longer duration of operation (P = 0:003), greater estimated blood loss (P = 0:001), and longer hospital stay (P &amp;lt; 0:001) and were more inclined to develop postoperative complications (P=0:047), particularly anastomotic leak (P=0:021) and severe (Clavien– Dindo grade III/IV) complications (P = 0:038). After multivariate analysis, previous intestinal resection (P = 0:019), preoperative use of steroids (P = 0:026), and ASA score of more than II (P &amp;lt; 0:001) were determined to be the independent prognostic risk factors for postoperative complications. During the 30-day follow-up period, there was no postoperative mortality or readmission. Conclusion Previous intestinal resection in patients with CD is an independent predictor of overall postoperative complications.

Development of a Clinical and Genetic Prediction Model for Early Intestinal Resection in Patients with Crohn’s Disease: Results from the IMPACT Study

Early intestinal resection in patients with Crohn’s disease (CD) is necessary due to a severe and complicating disease course. Herein, we aim to predict which patients with CD need early intestinal resection within 3 years of diagnosis, according to a tree-based machine learning technique. The single-nucleotide polymorphism (SNP) genotype data for 337 CD patients recruited from 15 hospitals were typed using the Korea Biobank Array. For external validation, an additional 126 CD patients were genotyped. The predictive model was trained using the 102 candidate SNPs and seven sets of clinical information (age, sex, cigarette smoking, disease location, disease behavior, upper gastrointestinal involvement, and perianal disease) by employing a tree-based machine learning method (CatBoost). The importance of each feature was measured using the Shapley Additive Explanations (SHAP) model. The final model comprised two clinical parameters (age and disease behavior) and four SNPs (rs28785174, rs60532570, rs13056955, and rs7660164). The combined clinical–genetic model predicted early surgery more accurately than a clinical-only model in both internal (area under the receiver operating characteristic (AUROC), 0.878 vs. 0.782; n = 51; p < 0.001) and external validation (AUROC, 0.836 vs. 0.805; n = 126; p < 0.001). Identification of genetic polymorphisms and clinical features enhanced the prediction of early intestinal resection in patients with CD.

Previous Intestinal Resection Is Associated with Postoperative Complications in Crohn's Disease: A Cohort Study.

Background To assess the influence of a previous intestinal resection on postoperative complications for Crohn's disease (CD). Methods Data on patients with CD undergoing surgery in our department from January 2016 through December 2019 were retrospectively reviewed. Information collected included demographic details, surgical data, and postoperative outcome. A cross-sectional study design was employed. Associations between postoperative complications and preoperative clinical indicators were further analyzed. Results Of the 129 patients with CD studied, 62 patients (48.06%) underwent previous resection. These patients were more likely to be older (P = 0.031), have longer disease duration (P = 0.025), use less 5-aminosalicylic acid/sulfasalazine preoperatively (P = 0.013), have lower body mass index (P = 0.003), and have a higher American Society of Anesthesiologists (ASA) Physical Status Classification System score (P = 0.043). Patients who had previous surgery had a longer duration of operation (P = 0.003), greater estimated blood loss (P = 0.001), and longer hospital stay (P < 0.001) and were more inclined to develop postoperative complications (P = 0.047), particularly anastomotic leak (P = 0.021) and severe (Clavien–Dindo grade III/IV) complications (P = 0.038). After multivariate analysis, previous intestinal resection (P = 0.019), preoperative use of steroids (P = 0.026), and ASA score of more than II (P < 0.001) were determined to be the independent prognostic risk factors for postoperative complications. During the 30-day follow-up period, there was no postoperative mortality or readmission. Conclusions Previous intestinal resection in patients with CD is an independent predictor of overall postoperative complications.

Predictors of irreversible intestinal resection in patients with acute mesenteric venous thrombosis.

Acute mesenteric venous thrombosis (AMVT) can cause a poor prognosis. Prompt transcatheter thrombolysis (TT) can achieve early mesenteric revascularization. However, irreversible intestinal ischemia still occurs and the mechanism is still unclear. To evaluate the clinical outcomes of and to identify predictive factors for irreversible intestinal ischemia requiring surgical resection in AMVT patients treated by TT. The records of consecutive patients with AMVT treated by TT from January 2010 to October 2017 were retrospectively analyzed. We compared patients who required resection of irreversible intestinal ischemia to patients who did not require. Among 58 patients, prompt TT was carried out 28.5 h after admission. A total of 42 (72.4%) patients underwent arteriovenous combined thrombolysis, and 16 (27.6%) underwent arterial thrombolysis alone. The overall 30-d mortality rate was 8.6%. Irreversible intestinal ischemia was indicated in 32 (55.2%) patients, who had a higher 30-d mortality and a longer in-hospital stay than patients without resection. The significant independent predictors of irreversible intestinal ischemia were Acute Physiology and Chronic Health Evaluation (APACHE) II score (odds ratio = 2.368, 95% confidence interval: 1.047-5.357, P = 0.038) and leukocytosis (odds ratio = 2.058, 95% confidence interval: 1.085-3.903, P = 0.027). Using the receiver operating characteristic curve, the cutoff values of the APACHE II score and leukocytosis for predicting the onset of irreversible intestinal ischemia were calculated to be 8.5 and 12 × 109/L, respectively. Prompt TT could achieve a favorable outcome in AMVT patients. High APACHE II score and leukocytosis can significantly predict the occurrence of irreversible intestinal ischemia. Therefore, close monitoring of these factors may help with the early identification of patients with irreversible intestinal ischemia, in whom ultimately surgical resection is required, before the initiation of TT.

Surgery in the age of biologics.

Since the introduction of the first anti-tumor necrosis factor antibodies in the late 1990s, biologic therapy has revolutionized the medical treatment of patients with inflammatory bowel disease (IBD). Nevertheless, surgery continues to play a significant role in treating IBD patients. Rates of intestinal resection in patients with Crohn’s disease or colectomy in ulcerative colitis are reducing but not substantially over the long term. An increasing variety of biologic medications are now available to treat IBD patients in various clinical situations. Consequently, a number of questions persist about how biologic medications affect the need for surgery and overall course in IBD patients. Given the trend for earlier and more frequent use of biologic medications in IBD patients, a working knowledge of the effects of these medications on surgical decision-making and outcomes is essential for the practicing colorectal surgeon and gastroenterologist. This review seeks to summarize the relevant literature surrounding biologic use and IBD surgery with a focus on the effect of biologics on the frequency, type and complications of surgery in this ‘age of biologics’.

P226 Systematic review with meta-analysis of individual data: impact of cut-off values on the performance of faecal calprotectin to detect endoscopic recurrence after intestinal resection in patients with Crohn’s disease

P226 Systematic review with meta-analysis of individual data: impact of cut-off values on the performance of faecal calprotectin to detect endoscopic recurrence after intestinal resection in patients with Crohn’s disease

Perianal pediatric Crohn disease is associated with a distinct phenotype and greater inflammatory burden

Growth deceleration and impaired pubertal growth spurt are common concerns in patients with early onset inflammatory bowel disease (IBD) (1-2). Previous studies confirmed the efficacy and safety of infliximab, an anti-tumor necrosis factor alpha (TNF-α) antibody, in achieving clinical remission in luminal Crohn’s disease (CD) and in facilitating linear growth (3). The present study describes in depth the specific characteristics of children with perianal CD (pCD), a sub-category of CD patients that appears to exhibit a higher level of inflammation. Previous studies reported a higher rate of intestinal resection in patients with pCD. As the authors state, the lack of this association in the present cohort could be linked to the currently recommended prompt start of anti-TNFa agents in the presence of perianal disease, that alters the natural history of the disease. This study reports reduced height Z-scores in children with pCD. It should be noted that height data were not correlated to the target height. Similarly, no data about growth velocity, pubertal stage and/or bone age of patients were available. For these reasons, it appears interesting to investigate in more detail the growth aspects in this sub-category of patients with IBD.

Asthma is not associated with the need for surgery in Crohn's disease when controlling for smoking status: a population-based cohort study.

PurposeGrowing evidence suggests asthma and Crohn’s disease commonly cooccur. However, the impact of asthma on the prognosis of Crohn’s disease is unknown. The aim of our study was to assess the effect of asthma on the need for intestinal resection in patients with Crohn’s disease while adjusting for smoking status, imputed from a smaller, secondary data set.Patients and methodsUsing health administrative data from a universally funded healthcare plan in Alberta, Canada, we conducted a cohort study to assess the effect of asthma on the need for surgery in patients with Crohn’s disease diagnosed between 2002 and 2008 (N=2,113). Validated algorithms were used to identify incident cases of Crohn’s disease, cooccurring asthma, and intestinal resection. The association between asthma and intestinal resection was estimated using multivariable Cox proportional hazards regression. Smoking status was imputed using a novel method using martingale residuals, derived from a data set of 485 patients enrolled in the Alberta Inflammatory Bowel Disease Consortium (2007 to 2014) who completed environmental questionnaires. All analyses were adjusted for age, sex, rural/urban status, and mean neighborhood income quintile.ResultsAsthma did not increase the risk of surgery in the health administrative data when not adjusting for smoking status (HR 1.03, 95% CI 0.81 to 1.29). The association remained nonsignificant after imputing smoking status in the health administrative data (HR 1.03, 95% CI 0.81 to 1.29).ConclusionAlthough asthma is associated with an increased risk of Crohn’s disease, co-occurring asthma is not associated with the risk of surgery in these patients. This null association persisted after adjusting for smoking status. This study described a novel method to adjust for confounding (smoking status) in time-to-event analyses, even when the confounding variable is unmeasured in health administrative data.

Stapled side-to-side anastomosis might be benefit in intestinal resection for Crohn's disease: A systematic review and network meta-analysis.

Intestinal anastomosis is an essential step in the intestinal resection in patients with Crohn's disease (CD). Anastomotic configuration such as handsewn end-to-end anastomosis (HEEA), stapled side-to-side anastomosis (SSSA) and so on may be a predictor of prognosis for postoperative CD patients. However, the association between anastomotic types and surgical outcomes are controversial. The aim of this review is to identify the optimal anastomosis for intestinal resection in patients with CD. Clinical trials comparing anastomosis after intestinal resection in patients with CD were searched in the database of MEDLINE, EMBASE, and the Cochrane Library. Outcomes such as postoperative hospital stay, complications, mortality, recurrence, and reoperation were evaluated. Pairwise treatment effects were estimated through a random-effects network meta-analysis based on the frequency framework by using the STATA software and reported as the estimated summary effect for each comparison between the 2 treatments in the network with a 95% credible interval. A total of 1113 patients in 11 trials were included. In pair-wise comparisons between groups, for overall postoperative complications, SSSA showed a more probability of superiority to HEEA; for complications other than anastomotic leak, anastomotic leak, wound infection, postoperative hospital stay and mortality, there were no significant difference between groups; for clinical recurrence, SSSA showed a more probability of superiority to HEEA; for reoperation, SSSA showed a more probability of superiority to HEEA. The number of eligible randomized controlled trails (RCTs) was small, and more than half of the included trials were retrospective studies; selection bias may lead to a less power in this assessment; follow-up time between different groups was different, which may possibly have affected the interpretation of the analysis of long-term outcome. By comprehensive analyzing all the postoperative outcomes, SSSA appeared to be the optimal anastomotic strategy after intestinal resection for patients with CD.

Associations Between the Prognostic Nutritional Index and Morbidity/Mortality During Intestinal Resection in Patients with Ulcerative Colitis.

Onodera's prognostic nutritional index (O-PNI) is a well-known predictor of the prognosis of several surgeries. The aim of this study was to evaluate the association between O-PNI and surgical outcome during surgery for ulcerative colitis (UC). This was a single-institution retrospective cohort study conducted in the Department of Inflammatory Bowel Disease at Hyogo College of Medicine, Japan. The preoperative predictive factors associated with mortality, morbidity, and pouch-related complications (PRCs) were examined separately from surgical procedure. A total of 1151 patients with UC who underwent surgery between January 2000 and December 2015 were included. Total colectomy (TC) alone, ileal pouch-anal anastomosis (IPAA) with ileostomy, and IPAA without ileostomy were performed in 254 patients, 736 patients, and 161 patients, respectively. Mortality and morbidity were found in nine (0.8%) and 320 (27.8%) patients, respectively. The median O-PNI score was 22.6 in patients with mortality and 35.6 in patients without mortality among TC alone (p<0.01). The significant predictive factors for mortality among TC alone were older age [p=0.03, odds ratio (OR) 6.8], higher C-reactive protein (p=0.02, OR 14.5), and O-PNI<24.9 (p=0.04, OR 5.6). Among IPAA with ileostomy, an American Society of Anesthesiologists score ≥3 (p=0.01, OR 2.3), prednisolone (PSL) dosage just before surgery ≥14mg/day (p=0.04, OR 1.8), and O-PNI<35.5 (p<0.01, OR 2.1) were predictors of PRCs. O-PNI did not predict PRCs among IPAA without ileostomy. Lower O-PNI may predict the prognosis in patients with UC. O-PNI may be a useful indicator for decision-making regarding surgical timing and procedure.

What Is the Risk of Anastomotic Leak After Repeat Intestinal Resection in Patients With Crohn's Disease?

Approximately half of Crohn's patients require intestinal resection, and many need repeat resections. The purpose of this study was to evaluate the increased risk of clinical anastomotic leak in patients with a history of previous intestinal resection undergoing repeat resection with anastomosis for Crohn's disease. This was a retrospective analysis of prospectively collected departmental data with 100% capture. The study was conducted at the department of colorectal surgery in a tertiary care teaching hospital between July 2007 and March 2016. A cohort of consecutive patients with Crohn's disease who were treated with intestinal resection and anastomosis, excluding patients with proximal fecal diversion, were included. The cohort was divided into 2 groups, those with no previous resection compared with those with previous resection. Clinical anastomotic leak within 30 days of surgery was measured. Of the 206 patients who met criteria, 83 patients had previous intestinal resection (40%). The 2 groups were similar in terms of patient factors, immune-suppressing medication use, and procedural factors. Overall, 20 clinical anastomotic leaks were identified (10% leak rate). There were 6 leaks (5%) detected in patients with no previous intestinal resection and 14 leaks (17%) detected in patients with a history of previous intestinal resection (p < 0.005). The OR of anastomotic leak in patients with Crohn's disease with previous resection compared with no previous resection was 3.5 (95% CI, 1.3-9.4). Patients with 1 previous resection (n = 53) had a leak rate of 13%, whereas patients with ≥2 previous resections (n = 30) had a leak rate of 23%. The number of previous resections correlated with increasing risk for clinical anastomotic leak (correlation coefficient = 0.998). This was a retrospective study with limited data to perform a multivariate analysis. Repeat intestinal resection in patients with Crohn's disease is associated with an increased rate of anastomotic leakage when compared with initial resection despite similar patient, medication, and procedural factors. See Video Abstract at http://links.lww.com/DCR/A459.

Sarcopenia is a predictive factor for intestinal resection in admitted patients with Crohn's disease.

The relationship between skeletal muscle volume and the prognosis of patients with inflammatory bowel disease (IBD) remains undetermined. We conducted a retrospective study of 72 IBD patients who were admitted to the hospital due to disease exacerbation. We enrolled IBD patients who had undergone abdominal computed tomography and assessed the nutritional indices, such as the Onodera’s prognostic nutritional index (O-PNI) and the controlling nutritional status (CONUT) index. The L3 skeletal muscle index (SMI), which is the ratio of the cross-sectional area of skeletal muscles at the level of the third lumbar (L3) vertebra to the height squared, was used to identify sarcopenia. Sarcopenia, defined as a low SMI, was observed in 42% of all IBD patients (37% with Crohn’s disease (CD) and 48% with ulcerative colitis (UC)). In UC patients, the O-PNI and CONUT values, height, and albumin levels were significantly lower than in CD patients. The SMI strongly correlated with sex, body weight, albumin level, and O-PNI in IBD patients. Multivariate analysis using the Cox regression model demonstrated that the presence of sarcopenia (P = 0.015) and disease type (CD or UC) (P = 0.007) were significant factors predicting intestinal resection. The cumulative operation-free survival rate was significantly lower for sarcopenic patients than in all IBD patients (P = 0.003) and a stratified analysis of CD patients (P = 0.001) using the Kaplan–Meier method and log-rank test. The L3 skeletal muscle area is a prognostic factor for intestinal resection in patients with CD.