Intra-abdominal Septic Complications Research Articles

Oral Budesonide and low serum albumin levels at surgery are associated with a higher risk of postoperative intra-abdominal septic complications after primary ileocaecal resection for Crohn's disease: A retrospective analysis of 853 consecutive patients

Background and AimsThe terminal ileum is the most frequent site of Crohn's Disease (CD) that necessitates surgery. Of the postoperative complications (POCs) associated with ileocaecal resection for CD, intra-abdominal septic complications (IASCs) include anastomotic leak, abscesses, and entero-cutaneous fistula.We aimed to identify predictors of IASCs and severe POCs (Clavien-Dindo ≥3) after primary ileocaecal resection for CD. MethodsThis is a retrospective single-centre cohort study including all consecutive primary ileocaecal resection for CD in a tertiary IBD centre between 2004 and 2021. ResultsA total of 853 patients underwent primary ileocaecal resection for CD. 307 (36.6 %) patients were receiving antibiotics, 253 (29.8 %), systemic steroids, and 178 (21.0 %) oral budesonide at surgery. At 90 days, 260 (30.8 %) patients developed POCs, 62 (7.3 %) severe POCs, and 56 (6.6 %) IASCs. At multivariate analysis, severe POCs were associated with lower preoperative albumin levels (OR1.58, 95 %CI 1.02–2.50, p = 0.040) and a history of cardiovascular diseases (OR2.36, 95 %CI 1.08–7.84, p = 0.030). IASCs were associated with lower preoperative albumin levels (OR1.81, 95 %CI 1.15–2.94, p = 0.011) and oral budesonide (OR2.07, 95 %CI 1.12–3.83, p = 0.021) with a dose-dependent effect. ConclusionsThe independent association, dose-dependent effect, and biological plausibility of budesonide and IASCs suggest a robust causal effect. Oral budesonide should be carefully assessed before primary ileocaecal resection for CD.

P414 Timing of biologics discontinuation is not associated with postoperative complications (POCs), infective complications, bleeding, or intra-abdominal septic complications (IASCs) after primary ileocecal resection for Crohn’s Disease: a retrospective analysis of 237 patients in a tertiary centre

Abstract Background The role of biologics on postoperative complications in Crohn’s Disease (CD) is still debated. Recent studies showed that preoperative adalimumab, infliximab, ustekinumab, and vedolizumab were not associated with increased POCs and IASCs. While some studies defined a 12-week cut-off based on pharmacodynamics principles, the safest timing for biologics discontinuation remains unknown. We aimed to analyse different timing of biologics discontinuation and POCs, infective complications, bleeding and IASCs after primary ileocecal resection for CD. Methods This is a retrospective single-centre study including all consecutive patients undergoing primary ileocecal resection for CD between 2004-2022 and exposed preoperatively to biologics. Patients were divided into four groups according to the number of weeks between the last dose of biologics and surgery: Group 1 (≤6 weeks), Group 2 (>6 and ≤12 weeks), Group 3 (>12 and ≤30 weeks), Group 4 (>30 weeks). The primary aim was POCs. Secondary aims were postoperative Clavien-Dindo≥III complications, infective complications, bleeding and IASCs. Uni- and multivariable logistic regression analyses were performed. Results We included 237 patients who underwent primary ileocecal resection for CD with previous exposition to biologics. Group 1 (≤6w) included 42 patients, Group 2 (≤12w) 41, Group 3 (≤30w) 47, and Group 4 (>30w) 107. Patients received adalimumab (128 pts, 54%), infliximab (82 pts, 35%), ustekinumab (15 pts, 6%) or vedolizumab (11 pts, 5%). Ileocecal resection with primary anastomosis was performed in 233 patients (98%) and 31 patients (13%) had a stoma. Groups were different in age, BMI, smoking, preoperative antibiotics, Albumin, Haemoglobin, and laparoscopy with Group 1 having higher rates of major risk factors for POCs. However, POCs, postoperative Clavien-Dindo≥III complications, infective complications, bleeding and IASCs were not different among the groups. Other general characteristics and postoperative outcomes of the four groups were reported in Table 1. Logistic regression analyses comparing the study outcomes among the groups were not able to detect differences as shown in Table 2 Conclusion The present study compared outcomes of different timing of biologics discontinuation for primary ileocecal resection for CD. No difference was found in POCs, postoperative Clavien-Dindo≥III complications, infective complications, bleeding and IASCs. Considering that patients treated with biologics ≤ 6 weeks before surgery had also a higher rate of risk factors for POCs and IASCs, biologics discontinuation seems not to have any impact on them. Large prospective multicentre studies are needed to confirm the safest period of preoperatory biologics discontinuation.

P214 Effects of rectal stump proctitis on short-term postoperative complications after proctectomy and ileal pouch-anal anastomosis for Ulcerative Colitis

Abstract Background Inflammation of the rectal stump (proctitis) after subtotal colectomy with ileostomy for ulcerative colitis (UC) is common. Proctitis may affect the postoperative outcomes of ileal pouch-anal anastomosis (IPAA). This study aims to explore associations between rectal stump proctitis and short-term postoperative complications (POCs) after proctectomy and IPAA for UC. Methods This retrospective single-centre study included patients who underwent proctectomy, IPAA and protective ileostomy for UC from 2000-2023. Data were retrieved from our prospectively-maintained database. Exclusion criteria were dysplasia or cancer (103 pts), missing pathology results (50 pts), undetermined colitis or Crohn’s Disease features at proctectomy (18 pts). All patients underwent three-staged IPAA and were divided into four groups according to the rectal stump proctitis status at pathology: remission, mild, moderate, and severe proctitis. A stepwise binary logistic regression analysis was performed for each short-term outcome. Models included variables with a different distribution according to the outcome (p-value ≤0.1). Results We included 785 patients who underwent proctectomy and IPAA. At pathology, remission was achieved by 162 (20.6%) patients, while proctitis of the rectal stump was mild in 211 (26.9%), moderate in 246 (31.3%), and severe in 166 (21.1%) patients, respectively. Table 1 details population characteristics and outcomes according to the proctitis status. Patients with moderate and severe proctitis received more preoperative biologics and ongoing systemic steroids at surgery. While they underwent previous abdominal surgery less frequently, the laparoscopy rate was lower with a longer postoperative length of stay. At multivariate (Table 2), Medical POCs were independently associated with ongoing antibiotics (OR 2.29 [1.01-5.20] p=0.047) and ASA score≥3 (OR 1.93 [1.11-3.35] p=0.019). Surgical POCs were independently associated with ongoing systemic steroids (OR 2.09 [1.19-3.68] p=0.011, while ongoing antibiotics (OR 0.2 [0.04-0.86] p=0.031) and laparoscopy (OR 0.53 [0.28-1.00] p=0.049) were protective. Intra-abdominal septic complications (IASCs) and abdominal/pelvic abscesses were independently associated with the proctitis status (OR 1.1 [1.06-2] p=0.018 and OR 1.56 [1.08-2.25] p=0.017, respectively). Conclusion Rectal stump proctitis was independently associated with postoperative abdominal and pelvic abscesses and IASCs after proctectomy and IPAA for UC. The association between proctitis and IPAA’s long-term outcomes and pouch failure need to be further explored.

Preoperative Exclusive Enteral Nutrition Is Associated With Reduced Skin and Soft Tissue and Intra-abdominal Infections in Patients With Crohn's Disease Undergoing Intestinal Surgery: Results from a Meta-Analysis.

Malnutrition is an independent risk factor for adverse postoperative outcomes and is common among patients with Crohn's disease (CD). The objective of this meta-analysis was to precisely quantify the association of preoperative exclusive enteral nutrition (EEN) and total parenteral nutrition (TPN) with surgical outcomes in patients undergoing intestinal surgery for CD. PubMed, Embase, and Scopus were queried for comparative studies evaluating the impact of preoperative nutritional support on postoperative outcomes in patients undergoing surgery for CD. Random effects modeling was used to compute pooled estimates of risk difference. Heterogeneity was assessed using I2. Fourteen studies, all nonrandomized cohort studies, met inclusion criteria for studying EEN. After pooling data from 14 studies (874 EEN treated and 1044 control patients), the relative risk of intra-abdominal septic complications was decreased 2.1-fold in patients receiving preoperative EEN (relative risk 0.47, 95% confidence interval [CI], 0.35-0.63, I2 = 0.0%). After pooling data from 9 studies (638 EEN treated and 819 control patients), the risk of skin and soft tissue infection was decreased 1.6-fold (relative risk 0.63; 95% CI, 0.42-0.94, I2 = 42.7%). No significant differences were identified in duration of surgery, length of bowel resected, or operative blood loss. Among the 9 studies investigating TPN, no significant differences were identified in infectious outcomes. Preoperative nutritional optimization with EEN was associated with reduced risk of infectious complications in CD patients undergoing intestinal surgery. Preoperative nutritional support with EEN should be considered for optimizing outcomes in CD patients requiring bowel resection surgery.

Clinical Update on the Prevention and Management of Postoperative Crohn's Disease Recurrence.

Despite advances in therapeutics, a significant portion of patients with Crohn's disease still require surgical management. In this article, we present updates to the natural history, prognostication and postoperative monitoring, and novel therapeutics in the prevention and treatment of postoperative Crohn's disease recurrence. Clinical risk factors have been associated with higher rates of postoperative recurrence (POR), and in recent studies demonstrate an increased cumulative risk with presence of additional risk factors. Additional novel clinical, histologic, and "-omic" risk factors for recurrence have recently been elucidated, including the role of the mesentery on recurrence and perioperative intraabdominal septic complications. High-risk patients benefit most from medical prophylaxis, including anti-TNF with or without immunomodulator therapy to prevent recurrence. New biologics such as vedolizumab and ustekinumab have emerging evidence in the use of prophylaxis, especially with recent REPREVIO trial data. Non-invasive disease monitoring, such as cross-sectional enterography, intestinal ultrasound, and fecal calprotectin, have been validated against ileocolonoscopy. Recent advances in the prediction, prevention, and monitoring algorithms of postoperative Crohn's disease may be leading to a reduction in postoperative recurrence. Ongoing trials will help determine optimal monitoring and management strategies for this at-risk population.

Faecal diversion remains central in the contemporary management of rectal trauma–Experience from a major trauma centre in South Africa

IntroductionThis paper provides an overview of a single centre's experience with rectal injury over a decade. It hopes to use this data to provide context to our current approach to managing these injuries in the civilian setting. The StudyAll patients with rectal trauma were identified from the Hybrid Electronic Medical Registry (HEMR). ResultsDuring the study period, a total of 88 patients with rectal injuries were admitted to Grey's Hospital in Pietermaritzburg. There were 80 (91 %) males and 8 (9 %) females. The median age was 31 (15–63) years. There were 9 (10 %) blunt mechanisms, 76 (86 %) penetrating mechanisms and 3 (4 %) combined blunt and penetrating mechanisms. Gunshot wounds accounted for the majority of sustained rectal trauma (71 %). There were 57 (65 %) extra-peritoneal injuries, 24 (27 %) intraperitoneal injuries and 7 (8 %) combined injuries. The grade of injury, according to the AAST grading system, was as follows, AAST 1: 16 (18 %), AAST 2: 63 (72 %), AAST 3: 7 (8 %), and AAST 4: 2 (2 %). Pre-sacral drainage and distal rectal washout were not performed. Almost all (55/57) of the extra-peritoneal rectal injuries were managed with proximal diversion (PD). There were five primary repairs (PR) performed in the extra-peritoneal rectal injury cohort. In four of these cases, this was accompanied by a PD. Of the 24 intraperitoneal rectal injuries, 15 underwent PR, of which 11 were performed in conjunction with PD. In total, 20 intraperitoneal rectal injuries underwent PD. All seven combined rectal injuries underwent PD, and three of the combined rectal injuries underwent PR with PD. There was urogenital tract associated morbidity in 8 %, gastrointestinal tract related morbidity in 8 % and septic complications in 11 %. ConclusionRectal trauma is still associated with a high rate of rectal/urogenital and infection related morbidity. Although pre-sacral drainage and distal stump washout have been largely abandoned in civilian practice, faecal diversion currently remains the cornerstone of the management of rectal trauma in our environment. Although there was a low rate of intra-abdominal septic complications in patients who had undergone diversion, this needs to be balanced against the low rate of stoma reversal.

Ileocolic resection for Crohn's disease: robotic intracorporeal compared to laparoscopic extracorporeal anastomosis.

Laparoscopy is the first-line approach in ileocolic resection for Crohn's disease. Emerging data has shown better short-term outcomes with robotic right colectomy for cancer when compared to laparoscopic approach. However, robotic ileocolic resection for Crohn's disease has only shown faster return to bowel function. We aimed to evaluate short-term outcomes of ileocolic resection for Crohn's disease between robotic intracorporeal anastomosis (RICA) and laparoscopic extracorporeal anastomosis (LECA). Patients undergoing minimally invasive ileocolic resections for Crohn's disease were retrospectively identified using a prospectively maintained database between 2014 and 2021 in two referral centers. Among the 239 patients, 70 (29%) underwent RICA while 169 (71%) LECA. Both groups were similar according to baseline and preoperative characteristics. RICA was associated with more intraoperative adhesiolysis and longer operative time [RICA: 238 ± 79min vs. LECA: 143 ± 52min; p < 0.001]. 30-day postoperative complications were not different between the two groups [RICA: 17/70(24%) vs. LECA: 54/169(32%); p = 0.238]. Surgical site infections [RICA: 0/70 vs. LECA: 16/169(10%); p = 0.004], intra-abdominal septic complications [RICA: 0/70 vs. LECA: 14/169(8%); p = 0.012], and Clavien-Dindo ≥ III complications [RICA: 1/70(1%) vs. LECA: 15/169(9%); p = 0.044] were less frequent in RICA. Return to bowel function [RICA: 2.1 ± 1.1 vs. LECA: 2.6 ± 1.2days; p = 0.002] and length of stay [RICA: 3.4 ± 2.2 vs. LECA: 4.2 ± 2.5days; p = 0.015] were shorter after RICA, with similar readmission rates. RICA demonstrated better short-term postoperative outcomes than LECA, with reduced Clavien-Dindo ≥ III complications, surgical site infections, intra-abdominal septic complications, shorter length of stay, and faster return to bowel function, despite the longer operative time.

Risk factors and therapeutic options for postoperative intra-abdominal septic complication in Crohn’s disease

Background: Approximately 70% of patients suffering from Crohns disease require surgery in their lifetime. The postoperative course is complex, with higher complication rates compared to major colorectal surgery and with a high incidence of Intra Abdominal Septic Complications (IASC).

P216 Oral Budesonide and low serum albumin levels at surgery are associated with a higher risk of postoperative intra-abdominal septic complications after primary ileocecal resection for Crohn’s disease: a retrospective analysis of 853 consecutive patients treated in a tertiary centre.

Abstract Background Patients undergoing ileocecal resection for Crohn’s disease (CD) are at high risk of postoperative intra-abdominal septic complications (IASC). The associated risk factors are still debated. The aim of the study was to identify the variables associated with IASC in patients treated for primary CD of the terminal ileum. Methods Retrospective single-centre study including consecutive patients undergoing ileocecal resection for CD between 2004-2021 and managed before surgery in a multidisciplinary IBD unit. Outcomes to identify the variables associated with IASC (primary aim) and severe complications, classified as Clavien-Dindo grade 3 and higher (secondary aim). The potential independent predictors of each outcome were evaluated using logistic regression. To reduce overfitting, all models were built including only the variables that were significant at univariate analyses, except for age, gender and history of cardiovascular diseases, that were included a priori. Standard diagnostic procedures were adopted to check all models validity: influential observation analysis (Dbeta, change in Pearson chi-square), Hosmer-Lemeshow test for the goodness of fit and C statistic (area under the Receiving Operator Curve). Results A total of 853 patients were included. Overall sample characteristics are shown in Table 1. Table 2 and Table 3 reported the comparison according to the primary (IASC) and secondary (severe complications) outcomes, respectively. Table 4 showed the multivariate analyses of the potential predictors of IASC and severe complications. The onset of IASC was associated with lower serum albumin level (OR 1.81, 95% CI 1.15-2.94, p=0.011) and the use of oral budesonide at time of surgery (OR 2.07, 95% CI 1.12-3.83, p= 0.021). The risk of severe complications was associated with a history of cardiovascular disease (OR 2.91, 95% CI 1.08-7.84, p=0.03) and lower serum albumin level (OR 1.58, 95% CI 1.02-2.50, p=0.04). Conclusion The present study analysed a large population of patients affected by CD of the terminal ileum who were treated homogeneously before surgery in a multidisciplinary setting and confirmed the significant impact of preoperative nutritional status on the risk of severe postoperative complications and IASC. The latter, however, was also associated with the use of oral budesonide at the time of surgery. This finding has not been previously reported in the literature. Based on the present evidence, oral budesonide should be discontinued or tapered to the lowest dose before surgery.

P489 Surgery for enterocutaneous fistula: the strongest predictor of postoperative mortality in Crohn’s disease patients

Abstract Background To access the risk of bowel resection in Crohn’s disease patients with enterocutaneous fistulae. Methods Consecutive patients undergoing intestinal resections for Crohn’ disease between 1992 and 2021 were included in the present prospective observational study. Exclusion criteria were: a) abdominoperineal resections for perianal disease, b) surgery for colorectal cancer complicating Crohn’s disease, c) abdominal surgery without intestinal resection (e.g. stoma formation or closure, mere adhesiolysis etc. Enterocutaneous fistulae occurring after previous bowel resection were named “postresection fistulae”, all other – “non-postresection fistulae”. Results 750 patients were included. At all, 70 patients (9%) underwent intestinal resections due to enterocutaneous fistulae. The frequency of surgery for enterocutaneous fistula decreased significantly during the last decade of the study (1992-2000: 13% of surgeries, 2001-2010: 12% of surgeries, 2011-2021: 6% of surgeries; p=0.05). The postoperative intraabdominal septic complication rate was 15% (n=111), six patients (0.8%) died. The mortality rate was 7% (5 of 79%) in patients with enterocutaneous fistulae. All latter death occurred only in patients with postresection fistulae. By multivariate analysis, surgery for enterocutaneous fistula (Hazard ratio 27.4, 95% CI: 2.9 – 255.6; p=0.004), age of 50 years and older (Hazard ratio 13.2; 95% CI: 2.0 – 87.7; p=0.008) and presence of intraabdominal abscess (Hazard ratio 11.8; 95% CI: 1.2 – 116.5; p=0.035) were associated with an increased risk of postoperative death. Age over 50 years was associated with an increased risk of death in patients with enterocutaneous fistulae (mortality rate 20% vs. 3.6%, Hazard ratio 16.61; 95% CI: 1.28 – 216.07; p=0.032). Conclusion Surgery for enteroctunaeous fistulae still poses significant risks, specially, when they occurred after bowel resection and in older patients.

The Effect of Anti-Tumor Necrosis Factor-Alpha Therapy within 12 Weeks Prior to Surgery on Postoperative Complications in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis.

The rate of abdominal surgical interventions and associated postoperative complications in inflammatory bowel disease (IBD) patients is still substantially high. There is an ongoing debate as to whether or not patients who undergo treatment with anti-tumor necrosis factor-alpha (TNF-α) agents may have an increased risk for general and surgical postoperative complications. Therefore, a systematic review and meta-analysis was conducted in order to assess the effect of anti-TNF-α treatment within 12 weeks (washout period) prior to abdominal surgery on 30-day postoperative complications in patients with IBD. The results of previously published meta-analyses examining the effect of preoperative anti-TNF-α treatment on postoperative complications reported conflicting findings which is why we specifically focus on the effect of anti-TNF-α treatment within 12 weeks prior to surgery. PubMed, Cochrane, Scopus, Web of Science, World Health Organization Trial Registry, ClinicalTrials.gov and reference lists were searched (June 1995−February 2022) to identify studies, investigating effects of anti-TNF-α treatment prior to abdominal surgery on postoperative complications in IBD patients. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated and subgroup analyses were performed. In this case, 55 cohort studies (22,714 patients) were included. Overall, postoperative complications (OR, 1.23; 95% CI, 1.04−1.45; p = 0.02), readmission (OR, 1.39; 95% CI, 1.11−1.73; p = 0.004), and intra-abdominal septic complications (OR, 1.89; 95% CI, 1.44−2.49; p < 0.00001) were significantly higher for anti-TNF-α-treated patients. Significantly higher intra-abdominal abscesses and readmission were found for anti-TNF-α-treated CD patients (p = 0.05; p = 0.002). Concomitant treatment with immunosuppressives in <50% of anti-TNF-α-treated patients was associated with significantly lower mortality rates (OR, 0.32; 95% CI, 0.12−0.83; p = 0.02). Anti-TNF-α treatment within 12 weeks prior to surgery is associated with higher short-term postoperative complication rates (general and surgical) for patients with IBD, especially CD.

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.

Intra-abdominal septic complications after ileocolic resection increases risk for endoscopic and surgical postoperative Crohn's disease recurrence.

Postoperative recurrence [POR] of Crohn's disease following ileocolonic resection is common. The impact of immediate postoperative intra-abdominal septic complications [IASC] on endoscopic and surgical recurrence has not been elucidated. To evaluate if IASC is associated with an increased risk for endoscopic and surgical POR. This was a retrospective study of adult Crohn's disease patients undergoing ileocolonic resection with primary anastomosis between 2009 and 2020. IASC was defined as anastomotic leak or intra-abdominal abscess within 90 days of the date of surgery. Multivariable logistic and Cox proportional hazard modelling were performed to assess the impact of IASC on endoscopic POR [modified Rutgeerts' score ≥ i2b] at index postoperative ileocolonoscopy and long-term surgical recurrence. In 535 Crohn's disease patients [median age 35 years, 22.1% active smokers, 35.7% one or more prior resection] had an ileocolonic resection with primary anastomosis. A minority of patients [N = 47; 8.8%] developed postoperative IASC. In total, 422 [78.9%] patients had one or more postoperative ileocolonoscopies, of whom 163 [38.6%] developed endoscopic POR. After adjusting for other risk factors for postoperative recurrence, postoperative IASC was associated with significantly greater odds (adjusted odds ratio [aOR]: 2.45 [1.23-4.97]; p = 0.01) and decreased time (adjusted hazards ratio [aHR]: 1.60 [1.04-2.45]; p = 0.03] to endoscopic POR. Furthermore, IASC was associated with increased risk (aOR: 2.3 [1.04-4.87] p = 0.03) and decreased survival-free time [aHR: 2.53 [1.31-4.87]; p = 0.006] for surgical recurrence. IASC is associated with an increased risk for endoscopic and surgical POR of Crohn's disease. Preoperative optimization to prevent IASC, in addition to postoperative biological prophylaxis, may help reduce the risk for endoscopic and surgical POR.

Perioperative outcomes of minimally invasive ileocolic resection for complicated Crohn disease: Results from a referral center retrospective cohort

BackgroundMinimally invasive ileocolic resection for complicated Crohn disease, defined as penetrating Crohn disease associated with intra-abdominal fistula, abscess, or phlegmon, is challenging. In addition, the impact of the minimally invasive approach on postoperative outcomes is still debated. This study aimed to compare the intraoperative and postoperative outcomes of minimally invasive ileocolic resection for complicated versus uncomplicated Crohn disease. MethodsA retrospective analysis of all consecutive adult patients with Crohn disease undergoing minimally invasive ileocolic resection from 2014 to 2021 was performed. Perioperative outcomes were compared between patients with complicated Crohn disease (complicated group) and patients without these lesions (uncomplicated group). ResultsAmong the 274 patients undergoing minimally invasive ileocolic resection for Crohn disease, 101 (36.9%) had a robotic approach, and 84 (30.7%) had complicated Crohn disease. Complicated patients were more frequently malnourished (32.1% vs 16.1%, P = .004) and had more frequent previous bowel resections for Crohn disease (22.1% vs 9.5%, P = .002). There were no differences between both groups regarding intraoperative complications (1.1% uncomplicated group vs 2.4% complicated group, P = .463), conversion rate (2.6% uncomplicated group vs 4.8% complicated group, P = .463), postoperative morbidity (27.4% uncomplicated group vs 34.5% complicated group, P = .231), intra-abdominal septic complications (4.2% uncomplicated group vs 7.1% complicated group, P = .309), and length of stay (3.8 ± 2.0 days uncomplicated group vs 4.2 ± 3.0 complicated group, P = .188). ConclusionMinimally invasive ileocolic resection for complicated Crohn disease is safe and feasible. Future prospective studies are needed to confirm these results.

Nonmetastatic ypt0 rectal cancer after neoadjuvant treatment and total mesorectal excision: Lessons from a retrospective multicentric cohort of 383 patients

BackgroundA better understanding of pathological features and oncological survival in ypT0 rectal cancer after neoadjuvant chemoradiotherapy is required to improve patient selection criteria for rectal-preserving approach by local excision. Our aim was to define risk of lymph node metastasis and oncological outcomes in ypT0 rectal cancer after chemoradiotherapy and total mesorectal excision. MethodsAll consecutive patients who underwent total mesorectal excision for a nonmetastatic rectal adenocarcinoma classified ypT0 after neoadjuvant chemoradiotherapy, with or without locoregional lymph node involvement (ypN+ or ypN-), in 14 French academic centers between 2002 and 2015 were included. Data were collected retrospectively. Overall and disease-free survival were explored. ResultsAmong the 383 ypT0 patients, 6% were ypN+ (23/283). Before chemoradiotherapy, 86% (327/380) were staged cT3-T4 and 41% (156/378) were staged cN+. The risk of ypN+ did not differ between cT3-T4 and cT1-T2 patients (P = .345) or between cN+ and cN- patients (P = .384). After a median follow-up of 61.1 months, we observed 95% confidence interval (92%–97%) of 5-year overall survival and 93% confidence interval (91%–96%) of 5-year disease-free survival. In Cox multivariate analysis, overall survival was altered by intra-abdominal septic complications (hazard ratio = 2.53, confidence interval [1.11–5.78], P = .028). Regarding disease-free survival, ypN+ status and administration of adjuvant chemotherapy were associated with a reduced disease-free survival (P = .001 for both). cT3/T4 staging and cN+ staging did not modify overall survival (P = .332 and P = .450) nor disease-free survival (P = .862 and P = .124). ConclusionThe risk of lymph node metastasis and the oncological survival do not depend on the initial cT or cN staging in cases of ypT0 complete rectal tumor regression.

CROHN’S DISEASE COMPLICATED BY ILEOSIGMOID FISTULA: ASSESSMENT AND MANAGEMENT UPDATE

Abstract BACKGROUND The preoperative evaluation of Crohn’s-related ileosigmoid fistula (ISF) is complex with multiple preoperative diagnostic modalities available. Intraoperative management is also complicated when deciding whether to repair the fistula or resect the involved sigmoid. How these choices impact outcomes is not clear. We aim to evaluate the impact of sigmoid resection versus conservative fistula repair on postoperative complications when treating ISF. METHODS Patients with Crohn’s disease (CD) undergoing ileocolic resection in the setting of an ISF between January 1, 2007 and December 31, 2017 were identified. A retrospective chart review was conducted to collect data on preoperative workup, intra-operative technique, and 30-day complications. Intra-abdominal sepsis was defined as the presence of an intra-abdominal abscess or anastomotic leak from the sigmoid colon postoperatively. Univariate comparisons were performed between those undergoing primary repair versus sigmoid resection with primary anastomosis. RESULTS 61 patients (62.3% female) with a median age of 37 years (range, 18-73)were included. Computed tomography enterography (CTE) and magnetic resonance enterography (MRE) each had a sensitivity of 100% versus 42% sensitivity for colonoscopy. When accounting for pre-operative endoscopy results, patients with endoscopic sigmoidal mucosal CD more often underwent sigmoid resection than patients with a normal sigmoidal mucosa or only a solitary fistulous opening in the sigmoid colon (p&amp;lt;0.001). When comparing primary repair vs sigmoid resection there was no difference in the occurrence of intra-abdominal septic complications (p=0.342) or anastomotic leak complication (p=0.239). CONCLUSION In summary, our study shows that conservative repair of the fistula is a safe option. Appropriate patient assessment and preoperative identification of the fistula is critical so that the management strategies for ISF and the potential implications can be discussed with the patient. CTE and MRE are the modalities of choice to diagnose ISF, while colonoscopy has a role in staging the burden of mucosal disease in the sigmoid colon. These tests help guide surgical decision-making with respect to resection versus primary repair of the sigmoid colon and will allow patients in whom the sigmoid colon is an innocent bystander to undergo a less extensive operation.

P538 Implementation of Kono-S anastomosis as a new standard of surgical care

Abstract Background The Kono-S ileocolic anastomosis is thought to reduce the risk of clinical and surgical recurrence in Crohn’s disease patients. The Kono-S anastomosis was established as a new standard of care at our institution in 2018, however, it was not performed in all patients. The present study describes the learning curve and reasons for hesitation to use the new technique. Methods Consecutive patients undergoing bowel resection with formation of ileocolic anastomosis since starting to use Kono-S technique were included in the present retrospective analysis. Intraabdominal septic complications (IASC) were peritonitis, anastomotic leak, intraabdominal fistula and abscess. Results Since starting to use Kono-S anastomosis, 90 patients underwent ileocolic resection (45M, 45F). However, during this period, conventional side-to-side ileocolic anastomosis was still performed in 26 patients (29%). Kono-S anastomosis was performed in 46% of cases during the first 6 months, in 76% during the next 6 months and in 82% of cases after the first year since implementation (p=0.005). There was no difference in postoperative IASC rate between patients with or without Kono-S anastomosis (2% vs. 4%, p=0.5). Also, postoperative overall complication rate, incidence of postoperative small bowel obstruction and length of postoperative hospital stay did not differ between groups. There were no anastomotic leaks. By the multivariate analysis, the presence of intraabdominal abscess or fistula (Hazard ratio 0.25, p=0.037) was the main reason to perform the conventional hand S/S anastomosis instead of new technique. Conclusion Some hesitation to use Kono-S anastomosis could be observed after the implementation of the new standard of care, especially during the first six months and in patients presenting with more complex intraabdominal findings. However, the learning curve has no impact on postoperative morbidity.

CROHN’S DISEASE COMPLICATED BY ILEOSIGMOID FISTULA: ASSESSMENT AND MANAGEMENT UPDATE

The preoperative evaluation of Crohn’s-related ileosigmoid fistula (ISF) is complex with multiple preoperative diagnostic modalities available. Intraoperative management is also complicated when deciding whether to repair the fistula or resect the involved sigmoid. How these choices impact outcomes is not clear. We aim to evaluate the impact of sigmoid resection versus conservative fistula repair on postoperative complications when treating ISF. Patients with Crohn’s disease (CD) undergoing ileocolic resection in the setting of an ISF between January 1, 2007 and December 31, 2017 were identified. A retrospective chart review was conducted to collect data on preoperative workup, intra-operative technique, and 30-day complications. Intra-abdominal sepsis was defined as the presence of an intra-abdominal abscess or anastomotic leak from the sigmoid colon postoperatively. Univariate comparisons were performed between those undergoing primary repair versus sigmoid resection with primary anastomosis. 61 patients (62.3% female) with a median age of 37 years (range, 18-73)were included. Computed tomography enterography (CTE) and magnetic resonance enterography (MRE) each had a sensitivity of 100% versus 42% sensitivity for colonoscopy. When accounting for pre-operative endoscopy results, patients with endoscopic sigmoidal mucosal CD more often underwent sigmoid resection than patients with a normal sigmoidal mucosa or only a solitary fistulous opening in the sigmoid colon (p<0.001). When comparing primary repair vs sigmoid resection there was no difference in the occurrence of intra-abdominal septic complications (p=0.342) or anastomotic leak complication (p=0.239). In summary, our study shows that conservative repair of the fistula is a safe option. Appropriate patient assessment and preoperative identification of the fistula is critical so that the management strategies for ISF and the potential implications can be discussed with the patient. CTE and MRE are the modalities of choice to diagnose ISF, while colonoscopy has a role in staging the burden of mucosal disease in the sigmoid colon. These tests help guide surgical decision-making with respect to resection versus primary repair of the sigmoid colon and will allow patients in whom the sigmoid colon is an innocent bystander to undergo a less extensive operation.Table 1Descriptive analysisView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Postoperative Safety Profile of Minimally Invasive Ileocolonic Resections for Crohn's Disease in the Era of Biologic Therapy.

There is controversy regarding the postoperative outcomes in Crohn's disease [CD] patients exposed to vedolizumab [VDZ] or ustekinumab [UST]. We aimed to describe our surgical outcomes in patients who underwent minimally invasive ileocolonic resection [MIS-ICR] for CD who had preoperative biologic therapy. All consecutive adult patients who had MIS-ICR for CD between 2014 and 2021 at our institution were included. Patients were divided into four groups: VDZ, UST, anti-tumour necrosis factor [anti-TNF], and no biologic group. Timing between the last dose of biologics and surgery was per surgeon's discretion. The primary outcome was intra-abdominal septic complications. Secondary outcomes included all 30-day complications. A total of 274 patients were identified. Of these, 113 [41.2%] patients had received anti-TNF, 52 [19%] had received UST, and 19 [7%] had received VDZ. There was no difference between the four groups regarding baseline risk factors. There was no difference between the four groups regarding intra-abdominal septic complications [4.4% for no biologic, 5.3% for anti-TNF, 5.8% for UST, and 5.3% for VDZ; p = 0.987], surgical site infection rate, overall 30-day morbidity, overall 30-day readmission, overall surgical and medical complications, urinary tract infection, pulmonary infections, or length of stay. Those results were consistent after a subgroup analysis based on complexity of the disease. This retrospective analysis demonstrates an equivalent postoperative safety profile for patients treated with preoperative anti-TNF, VDZ, or UST versus no biologic therapy within 3 months of MIS-ICR for Crohn's disease. Preoperative biologic therapy may not increase complications after minimally invasive ileocolonic resection in Crohn's disease. Further studies with larger sample sizes are needed to confirm results.

Special Considerations of Anastomotic Leaks in Crohn's Disease.

Rates of anastomotic leak following intestinal resections in the setting of inflammatory bowel disease are significantly influenced by clinical characteristics. While the literature can be contradictory due to significant heterogeneity in the published data, several common themes appear to consistently arise. With respect to Crohn's disease, low serum albumin, preoperative abscess, reoperative abdominal surgery, and steroid use are associated with an increased risk of postoperative intra-abdominal septic complications. On the contrary, biologic therapy, immunomodulator use, and method of anastomosis appear not to confer increased anastomotic-related complications. Undoubtedly, a low rate of anastomotic leakage is inherent to procedures within colorectal surgery but diligent attention must be paid to identify, optimize, and, therefore, reduce known risks.