Postoperative Clinical Recurrence Research Articles

Effect of Kono-S anastomosis on reducing postoperative recurrence rates in Crohn's disease: a systematic review and meta-analysis.

Kono-S anastomosis has gained increasing interest although evaluation of its impact on reducing Crohn's recurrence shows conflicting results. This study aimed to evaluate the short- and long-term outcomes for patients with Crohn's disease requiring surgery with Kono-S compared to conventional anastomosis. A systematic review and meta-analysis included patients with Crohn's disease treated with bowel resection and Kono-S anastomosis reconstruction versus a comparator arm of conventional anastomosis technique. Recurrence outcomes examined were endoscopic recurrence rates, mean postoperative Rutgeerts score, surgical recurrence, clinical recurrence, and postoperative biologics use. Short-term postoperative outcomes include anastomotic leaks, surgical site infection, postoperative ileus, and mean operative time. A total of 873 studies were identified with 15 remaining after abstract review encompassing 1501 patients, 765 with Kono-S and 736 with conventional anastomosis. Recurrence was significantly lower in the Kono-S arm, with endoscopic recurrence rates of 41% vs 48% (RR 0.86, 95%CI 0.73-1.00, p = 0.05) and surgical recurrence rates of 2.7% vs 21.0% (RR 0.13, 95%CI 0.06-0.30, p < 0.001). There was a significantly lower anastomotic leak rate in the Kono-S arm when compared to conventional anastomosis, 1.7% vs 4.9% (RR 0.37, 95%CI 0.19-0.74, p = 0.005). Mean operative time was similar between both groups. Kono-S is a safe and feasible anastomotic technique with lower rates of endoscopic and surgical postoperative recurrence. While we await further trials to substantiate this benefit, Kono-S anastomosis should be considered as an important tool in the armamentarium of a surgeon in anastomotic construction to reduce recurrence.

Long-term risk of delayed postoperative Crohn's disease recurrence in patients with no or mild endoscopic recurrence at first assessment.

Early endoscopic evaluation is recommended for assessment of postoperative recurrence (POR) of Crohn's disease (CD) but no further monitoring recommendations are available. To evaluate the long-term outcome of patients without endoscopic POR at first endoscopic assessment. Retrospective four-centre study including consecutive CD patients with ileocolonic resection (ICR) without endoscopic POR (Rutgeerts score i0-i1) at first endoscopic assessment performed within 18 months from ICR. All patients had a clinical follow-up ≥24 months and at least one further endoscopic assessment. Main outcomes were endoscopic, clinical and surgical POR, need for rescue therapy and "delayed POR" (any need for rescue therapy or clinical or surgical POR) during follow-up. Overall, 183 patients were included (79% with risk factors for POR, 44% without postoperative prophylaxis). Endoscopic POR was observed in 42% of patients. Clinical POR-free survival was 89.4% and 81.5% at 3 and 5 years, and delayed POR-free survival was 76.9% and 63.4% at 5 and 10 years, respectively. In multivariate analysis, postoperative prophylaxis (HR .55; 95% CI .325-.942) and active smoking (HR 1.72; 95%CI 1.003-2.962) were independent risk factors for clinical POR, whereas presence of mild endoscopic lesions at index ileocolonoscopy (i1) was the only risk factor for delayed POR (HR 1.824; 95% CI 1.108-3.002). Long-term risk of POR among patients with no or mild endoscopic lesions at first ileocolonoscopy after surgery is steadily low, being higher among smokers, in the absence of postoperative prophylaxis and when mild endoscopic lesions are observed in the first endoscopic assessment.

Association of the Stability Ratio With Postoperative Clinical Function and Recurrence of Instability in Patients With Anterior Shoulder Instability: A Retrospective Cohort Study

Background: The stability ratio (SR) is used to assess the stability of the glenoid in anterior shoulder instability (ASI). However, the association between the SR and postoperative clinical function and instability recurrence after arthroscopic Bankart repair is unknown. Hypothesis: Patients with a higher SR would have better postoperative clinical scores and a lower incidence of recurrent instability than patients with a lower SR after arthroscopic Bankart repair. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 62 patients who underwent arthroscopic Bankart repair for ASI between 2013 and 2019 were enrolled. All patients had at least 2 years of follow-up data. The preoperative SR was calculated via biomechanical testing based on patient-specific 3-dimensional glenoid models, and patients were evenly divided into 2 groups: high SR (≥16.13%) and low SR (&lt;16.13%). Baseline information (patient characteristics, clinical history, bone defect area [BDA], and SR), clinical scores at the final follow-up (Single Assessment Numerical Evaluation, Western Ontario Shoulder Index, and American Shoulder and Elbow Surgeons), and instability recurrence were compared between the 2 groups. Results: No significant differences were found in the baseline information between the high- and low-SR groups, except for the BDA (8.5% [high-SR group] vs 11.9% [low-SR group]; P = .01). No patients in the high-SR group had recurrent instability, while 6 patients (19.4%) had recurrent instability in the low-SR group ( P = .02). Patients in the high-SR group had superior clinical outcomes compared with those in the low-SR group in terms of postoperative Western Ontario Shoulder Index scores (median, 205 vs 410, respectively; P = .006) and American Shoulder and Elbow Surgeons scores (median, 98.3 vs 95, respectively; P = .02). Conclusion: In the present study, the SR was significantly associated with postoperative clinical function and recurrence of instability after arthroscopic Bankart repair in patients with ASI.

P841 Exploring Factors Influencing Rutgeerts Score Changes After Ileocecal Resection in Crohn's Disease Patients

Abstract Background Ileocecal resection (ICR) is the most common surgery in Crohn's disease patients with a high risk of postoperative endoscopic and clinical recurrence. The Rutgeerts score is an endoscopic tool used to predict postoperative clinical recurrence and guide therapeutic management. The aim of this study is to identify factors influencing the evolution of this score. Methods We included all Crohn's disease patients undergoing ICR and who had undergone at least two postoperative colonoscopies during the period [2019-2023]. at the Hepato-Gastroenterology Department of MOHAMMED VI university hospital of Oujda,Morocco. Results Forty-six Crohn's disease patients underwent ICR, including 19 females and 27males (sex ratio M/F: 1.4). The mean age of patients was 36 years [26-73], with an average duration of 4 years between diagnosis and ICR. The mean time between surgery and the first follow-up colonoscopy was 10 months, with an average of 18 months between two follow-up colonoscopies. Endoscopic results revealed stability in the Rutgeerts score for 22 patients without the appearance of clinical recurrence signs. Among these patients, 40% were on immunosuppressants (methotrexate n=5, thiopurines n=4), and 60% were on combination therapy. Worsening of the Rutgeerts score was noted in 13 patients, including 30% with perianal manifestations (PAM), 23% with stomas or those who underwent a second surgical intervention during the interval between two colonoscopies, 37% with therapeutic non-adherence, and 10% who stopped treatment. Improvement in the Rutgeerts score was observed in 11 patients, half of whom underwent therapeutic switching or optimization.Identified factors included the use of immunosuppressants or combination therapy, PAM, therapeutic non-adherence, the occurrence of surgery, stomas, therapeutic switching, or optimization. Conclusion In conclusion, our study highlights the complexities in post-ileocecal resection management for Crohn's disease. While stability in Rutgeerts scores was observed in some patients, factors such as perianal manifestations, stomas, and therapeutic non-adherence were associated with score worsening. These findings underscore the need for personalized approaches to optimize postoperative care and inform therapeutic decisions in Crohn's disease patients undergoing ileocecal resection.

P440 Myenteric plexitis and active inflammation at surgical margins are high-risk predictors for postoperative clinical recurrence of Crohn’s disease

Abstract Background Preventing postoperative recurrence is an important issue for clinical management of Crohn’s disease (CD). Identification of practical risk factors and an effective prophylactic treatment strategy has been desired for the prevention of postoperative recurrence. Although some of the clinical risk factors have been applied to select candidates for prophylactic treatments, these attempts have not fully prevented postoperative recurrence. In this study, we investigate the histological features at resected margins which predicted postoperative recurrence, and whether the initiation of prophylactic treatments could prevent postoperative recurrence in these cases. Methods We retrospectively reviewed the clinical recurrence rate in CD patients who underwent intestinal resection between January 2019 and December 2021. Clinical recurrence was defined by combination of serological, radiographic, and endoscopic findings or treatment escalation. To assess the histological risk factors for postoperative recurrence, resection margins of the surgical specimens were evaluated for the presence of myenteric plexitis, granulomas, and active inflammation. Each histological feature was evaluated from Grade 0 to 3. We also examined the ability of prophylactic treatments to prevent postoperative recurrence stratified with histological findings related to clinical recurrence rates. Results Of the 141 patients included in this study, 61.9% had plexitis (grade 3:Inflammatory cells at myenteric plexus, 10&amp;gt;HPF) at the proximal margin and 13.5% had active inflammation (grade 3: erosion or ulcer) at the distal margin. Log rank test identified the presence of plexitis (Grade3) (HR:1.84, 95%CI [1.05-3.22], p=0.029) at the proximal margin and active inflammation (Grade3) at the distal margin (HR:1.29, 95%CI [1.05-1.58], p=0.012) as possible risks of clinical recurrence (Figure). Multivariate analysis confirmed that the presence of plexitis (Grade3) at the proximal margin (HR 1.82, 95% CI 1.04-3.21, P=0.038) and active inflammation (Grade 3) at the distal margin (HR 2.31, 95% CI 1.18-4.46, P=0.013) were associated with postoperative clinical recurrence. Prophylactic use of immunomodulators (IM) and biologics did not show a significant reduction of clinical recurrence compared to treatment without IM and/or biologics in patient with histological risk factors (Table). Conclusion Our results indicate that the presence of plexitis in the proximal margin and active inflammation in the distal margin of the resected intestine are risk factors for postoperative recurrence. In these cases, initiation of prophylactic treatments with biologics and/or IM may not prevent the clinical recurrence.

P573 Simplified MARIA score does not predict long-term outcomes in Crohn’s disease patients undergoing modified side-to-side strictureplasty for extensive ileitis

Abstract Background Strictureplasty techniques were developed to limit the risk of short bowel syndrome in Crohn’s disease (CD) patients with affected small intestine. In the setting of extensive small bowel disease, long strictures might be treated with modified side-to-side isoperistaltic strictureplasty (SSIS). We studied long-term outcomes in patients who underwent SSIS and evaluated if radiological features on MR enterography (MRE) predict them. Methods This retrospective study included CD patients who underwent SSIS, for whom preoperative and six-month postoperative MRE were routinely performed. Simplified MARIA (MARIAs) score, considering wall thickness, edema, fat stranding and ulcers (score &amp;gt;1 active CD; maximum 5) was used. Improvement in maximal wall thickness was defined as decrease of at least 30% from baseline. Deep remission was defined as absence of symptoms and endoscopic remission (mRutgeerts score ≤i1), and clinical recurrence as occurrence of new symptoms confirmed by endoscopy (mRutgeerts score ≥i2b) or radiology (new strictures/inflammation) requiring treatment. Clinical data were collected from medical records. The correlation between recurrence and features within the MARIAs score was assessed. Results Thirty CD patients underwent SSIS and had pre- and six-month postoperative MRE (table). Immediately after surgery, 13 (43.3%) patients were continued or initiated on advanced therapy. Over a median [IQR] follow-up of 7.4 [3.3-9.3] years, 17 (56.7%) patients showed clinical recurrence of whom 6 (20.0%) needed surgical reintervention (figure). Deep remission was observed in 8 (26.7%) patients. Preoperatively, all patients had a maximum MARIAs score of 5. After surgery, the median [IQR] change in MARIAs score was 0.0 [0.0-0.8]. Cox regression analysis showed no association between decrease in overall MARIAs score, nor separate components of this score, with clinical or surgical recurrence free survival. Wall thickness decrease of &amp;gt;30%, observed in 15 (50%) patients, showed a trend for clinical recurrence free survival (p=0.098). Three patients showed normalization of MARIAs score and showed no recurrence thereafter. None of the clinical variables collected showed significant association with recurrence, except for immediate postoperative advanced therapy which had a 70% protection from clinical recurrence [p=0.036 / HR 0.3 (0.097-0.92)]. Conclusion Long-term follow-up of CD patients undergoing SSIS showed that 57% of patients had clinical recurrence and 20% needed surgical reintervention. The MARIAs score was not predictive of long-term postoperative clinical or surgical recurrence as most features of the score remained unaltered. These shortcomings of the MARIAs score should be addressed when designing improved scoring tools.

P263 Clinical-Endoscopic Correlation of Postoperative Recurrence in Surgically Treated Crohn's Disease Patients

Abstract Background The majority of patients with Crohn's disease (CD) require surgical intervention at some point in their disease course, particularly ileocolic resection. However, the average rate of clinical postoperative relapse is 30% at 3 years and 60% at 10 years. Endoscopic postoperative recurrence precedes clinical recurrence, highlighting the importance of conducting a colonoscopy 6 to 12 months postoperatively to establish the Rutgeerts score,which predicts the risk of clinical recurrence. The aim of this study is to correlate endoscopic findings with the clinical symptoms of these patients. Methods We retrospectively analyzed clinical symptoms and Rutgeerts scores of Crohn's disease patients who underwent ileocolic resection during the course of their disease, and followed at the Hepato-Gastroenterology Department of MOHAMMED VI university hospital in Oujda, Morocco, during the period [2018-2023] Results Sixty Crohn's disease patients underwent at least one surgical operation during the course of their disease, comprising 25 females and 35 males with a sex ratio (M/F: 1.4). The average age of our patients was 35 years [20-73]. The average time between diagnosis and the first surgery was 4 years. All these patients received postoperative medical treatment before colonoscopy, including azathioprine or methotrexate in 26 patients (43%) and anti-TNF in 34 cases (56%), with an average time of 8 months between surgery and the start of treatment. According to the Montreal classification, the ileocolic form dominated in 88% of cases, with a penetrating phenotype in 40% and a structuring phenotype in 60%. The operative indication was primarily obstructive syndromes in 85% of cases and collections in15%. The average time to perform colonoscopy after surgery was 10 months. During follow-up, 80% of patients were asymptomatic post-surgery, with Rutgeerts scores of I0-I1 in 11(23%) patients, I2 in 13 (27%) cases, I3 in 9 (19%) cases, and I4 in 15 (31%) cases.However, clinical recurrence, characterized by diarrhea, abdominal pain, or Koenig's syndrome, was observed in 20% of patients, with an average postoperative clinical recurrence time of 2 years. The endoscopic findings in these patients revealed Rutgeerts scores of I2 in 4 cases (33%), I3 in 3 cases (25%), and I4 in 5 cases (41%). Conclusion In summary, despite postoperative medical management, the risk of clinical recurrence isnotable. Early postoperative colonoscopy, assessing Rutgeerts scores, proves crucial inpredicting clinical recurrence risk. The observed clinical-endoscopic discordance emphasizes the need for a comprehensive approach to monitoring postoperative outcomes in Crohn's disease.

Role of visceral fat on postoperative complications and relapse in patients with Crohn's disease after ileocecal resection: Is it overrated?

The role of visceral fat in disease development, particularly in Crohn´s disease (CD), is significant. However, its preoperative prognostic value for postoperative complications and CD relapse after ileocecal resection (ICR) remains unknown. This study aims to assess the predictive potential of preoperatively measured visceral and subcutaneous fat in postoperative complications and CD recurrence using magnetic resonance imaging (MRI). The primary endpoint was postoperative anastomotic leakage of the ileocolonic anastomosis, with secondary endpoints evaluating postoperative complications according to the Clavien Dindo classification and CD recurrence at the anastomosis. We conducted a retrospective analysis of 347 CD patients who underwent ICR at our tertiary referral center between 2010 and 2020. We included 223 patients with high-quality preoperative MRI scans, recording demographics, postoperative outcomes, and CD recurrence rates at the anastomosis. To assess adipose tissue distribution, we measured total fat area (TFA), visceral fat area (VFA), subcutaneous fat area (SFA), and abdominal circumference (AC) at the lumbar 3 (L3) level using MRI cross-sectional images. Ratios of these values were calculated. None of the radiological variables showed an association with anastomotic leakage (TFA p = 0.932, VFA p = 0.982, SFA p = 0.951, SFA/TFA p = 0.422, VFA/TFA p = 0.422), postoperative complications, or CD recurrence (TFA p = 0.264, VFA p = 0.916, SFA p = 0.103, SFA/TFA p = 0.059, VFA/TFA p = 0.059). Radiological visceral obesity variables were associated with postoperative outcomes or clinical recurrence in CD patients undergoing ICR. Preoperative measurement of visceral fat measurement is not specific for predicting postoperative complications or CD relapse.

Major Abdominal Surgery for Pediatric Crohn's Disease in the Anti-TNF Era: 10-Year Analysis of Data From the IBD Registry of Italian Society of Pediatric Gastroenterology, Hepatology, and Nutrition.

The natural history of Crohn's disease (CD) can result in complications requiring surgery. Pediatric data are scarce about major abdominal surgery. The IBD Registry from the Italian Society of Pediatric Gastroenterology, Hepatology, and Nutrition has been active since 2008 and collects data from major pediatric IBD centers in Italy. The aim of the present report was to explore the prevalence of major abdominal surgery among children affected by CD in an era when antitumor necrosis factor (anti-TNF-α) agents were already used so that we might appraise the incidence of surgical-related complications and identify the factors associated with postoperative disease recurrence. We retrospectively analyzed data from patients enrolled in the registry from January 2009 to December 2018. Patients with monogenic IBD and patients undergoing surgery for perianal disease were excluded. In total, 135 of 1245 patients were identified. We report the prevalence of major abdominal surgery of 10.8%. Pediatric surgeons performed the procedure in 54.1% of cases, and a laparoscopic approach was used in 47.4% of surgical procedures. Seventeen patients (12.6%) experienced a total of 21 early postoperative complications, none of which was severe. A laparoscopic approach was the only factor negatively associated with the occurrence of postoperative complications (odds ratio, 0.22; 95% confidence interval, 0.06-0.8; P = .02). Fifty-four (40%) patients experienced postoperative endoscopic recurrence, and 33 (24.4%) of them experienced postoperative clinical recurrence. The postoperative treatment with anti-TNF-α drugs was significantly associated with a reduced risk of endoscopic recurrence (odds ratio, 0.19; 95% confidence interval, 0.05-0.79; P = .02). In our cohort, the overall prevalence of major abdominal surgery was low, as well as the rate of surgical-related complications. Postoperative anti-TNF-α therapy seems be protective against endoscopic recurrence.

Rational design of NIR-II molecule-engineered nanoplatform for preoperative downstaging and imaging-guided surgery of orthotopic hepatic tumor

Orthotopic advanced hepatic tumor resection without precise location and preoperative downstaging may cause clinical postoperative recurrence and metastasis. Early accurate monitoring and tumor size reduction based on the multifunctional diagnostic-therapeutic integration platform could improve real-time imaging-guided resection efficacy. Here, a Near-Infrared II/Photoacoustic Imaging/Magnetic Resonance Imaging (NIR-II/PAI/MRI) organic nanoplatform IRFEP-FA-DOTA-Gd (IFDG) is developed for integrated diagnosis and treatment of orthotopic hepatic tumor. The IFDG is designed rationally based on the core “S-D-A-D-S” NIR-II probe IRFEP modified with folic acid (FA) for active tumor targeting and Gd-DOTA agent for MR imaging. The IFDG exhibits several advantages, including efficient tumor tissue accumulation, good tumor margin imaging effect, and excellent photothermal conversion effect. Therefore, the IFDG could realize accurate long-term monitoring and photothermal therapy non-invasively of the hepatic tumor to reduce its size. Next, the complete resection of the hepatic tumor in situ lesions could be realized by the intraoperative real-time NIR-II imaging guidance. Notably, the preoperative downstaging strategy is confirmed to lower the postoperative recurrence rate of the liver cancer patients under middle and advanced stage effectively with fewer side effects. Overall, the designed nanoplatform demonstrates great potential as a diagnostic-therapeutic integration platform for precise imaging-guided surgical navigation of orthotopic hepatic tumors with a low recurrence rate after surgery, providing a paradigm for diagnosing and treating the advanced tumors in the future clinical translation application.Graphical

Granuloma Presence at Initial Surgery Predicts Need for Repeat Surgery Independent of Rutgeerts Score in Crohn's Disease.

Approximately half of Crohn's disease (CD) patients experience recurrence and need for repeat resections, highlighting need for prognostic biomarkers. Presence of epithelioid granuloma on surgical tissue and high Rutgeerts endoscopic score are associated with postoperative CD clinical recurrence. We sought to evaluate presence of epithelioid granuloma at first surgery and Rutgeerts score as a combined risk assessment for CD surgical recurrence. Our study included consented CD patients who underwent initial ileocecal resection and were prospectively followed postoperatively. From 2009 to 2019, 418 CD patients underwent initial ileocecal resection with >4 years of follow-up, including postoperative endoscopic assessment (Rutgeerts score). Postoperative CD patients were grouped based on granuloma presence (30.6%; n = 128) or absence (69.4%; n = 290). Endoscopic recurrence (defined as Rutgeerts score ≥i2) was similar between the granuloma (26%) and no granuloma (25%) groups, respectively (P = .82). Patients with granuloma and CD endoscopic recurrence at first postoperative endoscopy had higher number of bowel surgeries compared with all other groups (no granuloma or CD endoscopic recurrence, P = .007; no granuloma but CD endoscopic recurrence present, P = .04; granuloma present and no CD endoscopic recurrence, P = .04). Epithelioid granuloma presence was associated with 1.65 times higher risk of subsequent surgery independently from first postoperative endoscopic recurrence Rutgeerts score. Granuloma presence on initial surgical histology is immediately available and identifies high-risk CD patients who may benefit from early postoperative treatment, and these precision intervention trials are warranted.

P429 Patient skeletal muscle area and postoperative clinical recurrence in Crohn’s disease: a retrospective study

Abstract Background Sarcopenia, a reduction in muscle mass and function, is a poorly recognised phenomenon in Crohn’s disease (CD) despite occurring in 16%-68% of CD patients [1-5]. It has been linked to both an increased need for surgery and increased risk of postoperative complications. However, the role of sarcopenia in CD and its long-term impact on surgical outcomes are unknown. We aimed to assess the link between sarcopenia and postoperative clinical recurrence. Methods Retrospective data was collected between 2015 and 2021 from CD patients who had undergone gastrointestinal surgery and a MR or CT scan within 3 months prior to surgery. Follow up data was retrospectively collected for 6 months. MR and CT scans were used to determine skeletal muscle area (SMA) from the cross-sectional L3 vertebrae, which was used to identify patients as sarcopenic or not. Clinical recurrence was defined as a Harvey-Bradshaw Index of 5 or more. Statistical analysis included demographics and inferential analyses. Missing data was attributed to the absence in clinic notes. Results This single centre study included 64 CD patients [56.3% male, median age of 30.0 (18.0-76.0), 87.7% non-smokers] who had undergone gastrointestinal surgery. Most patients had ileocolonic CD (74.6%, 47/63) and either stricturing (46.9%, 30/64) or penetrating (31.3%, 20/64) disease behaviour, and 23.4% (15/64) had perianal disease. 45.3% (29/64) of patients had had at least one previous surgery. Preoperatively, 20.6% (13/63) of patients were on steroids and 55.6% (35/63) were on combined drug therapy. Patient median SMA was 113.6 (61.8 – 281.7) cm2 with sarcopenia found in 74.1% (43/58) of patients. SMA was lower in females (females: 92.1±19.3 cm2 vs males: 137±39.5 cm2, p&amp;lt;0.001) and patients with a BMI&amp;lt;18.5 kg/m2 (BMI&amp;lt;18.5 kg/m2: 91.8±19.1 cm2 vs BMI≥18.5 kg /m2: 120.3±33.3 cm2, p=0.004) (figure 1). Postoperative clinical recurrence was observed in 17.8% (8/45) of patients at 6 months. Patients with clinical recurrence had a significantly lower SMA (87.4 ± 18.5 cm2) compared to those without clinical recurrence (120.9 ± 39.2 cm2) (p=0.001) (figure 2). Patients with a lower SMA were 1.1 times more likely to have clinical recurrence at 6 months compared to patients with a higher SMA (OR 1.05 (CI 1.01-1.10)(p=0.022)). Conclusion Sarcopenia is highly prevalent in preoperative CD patients. Patients with early clinical recurrence had a significantly lower SMA. SMA may be useful in predicting CD patients at risk of early postoperative clinical recurrence. However, more research is needed to confirm study findings.

Comparison of the risk of Crohn's disease postoperative recurrence between modified Rutgeerts score i2a and i2b categories: an individual patient data meta-analysis.

The modified Rutgeerts' score differentiates i2a - lesions confined to the anastomosis - and i2b - more than 5 aphthous ulcers in the neoterminal ileum with normal intervening mucosa, with or without anastomotic lesions - categories. Its relevance for the therapeutic management of Crohn's disease (CD) patients after ileocolic resection is still debated. Our objective was to compare the postoperative recurrence risk in patients with an i2a or i2b score using an individual patient data meta-analysis. We conducted a systematic literature search until July 2020 to identify all relevant studies reporting the i2a/i2b status in the year following ileocolic resection and clinical and/or surgical postoperative CD recurrence in their follow-up. Individual patient level data were obtained from the corresponding authors. The association between the modified RS and time-to-event was evaluated using a mixed Cox model with the center as the random effect. Seven studies published between 2008 and 2019 were included corresponding to 400 patients: 189 (47%) i2a and 211 (53%) i2b. Median (interquartile range, IQR) time from ileocolic resection to ileocolonoscopy was 6.2 (5.5, 7.9) months and median (IQR) follow-up time after ileocolonoscopy was 4.5 (2.9, 7.3) years. The risk of clinical postoperative recurrence at 1 and 3 years was 11% [6%-15%], and 25% [18%-32%] in the i2a group versus 9% [5%-13%] and 33% [26%-41%] in the i2b group (p=0.63 and p=0.12, respectively). No significant difference was observed in terms of time to clinical postoperative recurrence (p=0.16) or surgical postoperative recurrence (p=0.87). Results did not change after excluding patients having initiated an immunosuppressant or a biologic in the three months after endoscopy (remaining cohort, n=361). In this individual patient data meta-analysis, no difference was observed between i2a and i2b subcategories with regards to clinical or surgical postoperative recurrence. As we wait for prospective trials, the same treatment strategy could be applied to all patients classified as i2 on the Rutgeerts score.

Top-down Versus Step-up Strategies to Prevent Postoperative Recurrence in Crohn's Disease.

The best management after ileocolonic resection is still unknown in Crohn's disease (CD). We compared step-up and top-down approaches to prevent short and long-term postoperative recurrences in CD patients. From a comprehensive database, consecutive CD patients who underwent intestinal resection (2014-2021) were included. Top-down (biologics started within the first month after surgery) or step-up strategies (no biologic between surgery and colonoscopy at 6 months) were performed with systematic colonoscopy at 6 months and therapeutic escalation if Rutgeerts index was ≥i2a (endoscopic postoperative recurrence). Propensity score analysis was applied for each comparison. Among 115 CD patients, top-down was the most effective strategy to prevent endoscopic postoperative recurrence (46.8% vs 65.9%, P = .042) and to achieve complete endoscopic remission (Rutgeerts index = i0; 45.3% vs 19.3%; P = .004) at 6 months. We did not observe any significant difference between the 2 groups regarding clinical postoperative recurrence (hazard ratio [HR], .86 [0.44-1.66], P = .66) and progression of bowel damage (HR, 0.81 [0.63-1.06], P = .12). Endoscopic postoperative recurrence at 6 months was associated with increased risk of clinical postoperative recurrence (HR, 1.97 [1.07-3.64], P 0.029) and progression of bowel damage (HR, 3.33 [1.23-9.02], P = .018). Among the subgroup without endoscopic postoperative recurrence at 6 months, the risks of clinical postoperative recurrence and progression of bowel damage were significantly improved in the top-down group (HR, 0.59 [0.37-0.94], P = .025; and HR, 0.73 [0.63-0.83], P < .001, respectively). Top-down strategy should be the preferred management to prevent short and long-term postoperative recurrence in CD.

Totally stapled Kono-S anastomosis for Crohn's disease.

Postoperative recurrence (POR) rates after resection for Crohn's disease (CD) are high. Whether the type of anastomosis affects POR is still debated. Recently, an anti-mesenteric hand-sewn end-to-end anastomosis (Kono-S) has been proposed as an additional measure to reduce recurrence. A randomized controlled trial demonstrated a significant reduction of endoscopic and clinical POR when the Kono-S anastomosis was compared to stapled ileocolic side-to-side anastomosis. However the hand- sewn technique might potentially limit use of this new type of anastomosis. The aim of this paper was to illustrate the technique of a totally stapled Kono-S anastomosis, and to discuss its potential advantages in surgery for CD.

DOP34 Comparison of the risk of clinical recurrence after ileocolonic resection for Crohn’s Disease for modified Rutgeerts’ score i2a and i2b categories: Individual patient data meta-analysis

Abstract Background The modified Rutgeerts’ score (mRS) differentiates i2a – lesions confined to the anastomosis – and i2b – neoterminal ileum lesions – categories. Its relevance for therapeutic management of Crohn’s disease (CD) patients after ileocolonic resection is still debated. Our objective was to compare the postoperative recurrence (POR) risk in patients with a mRS i2a or i2b score using an individual patient data meta-analysis. Methods We conducted a systematic literature search of Medline, Embase and abstracts from international conferences (until July 2020) to identify all relevant studies reporting the risk of clinical and/or surgical POR and the i2a/i2b status in the year following ileocolonic resection. Initial datasets were obtained from the corresponding authors. Time from endoscopy to clinical and surgical POR was estimated using Kaplan-Meier method. The association between time to event and mRS was evaluated using a mixed Cox with centre as the random effect. Results From the 17 studies identified, 7 published between 2008 and 2019 (cohort studies, n=4; clinical trials, n=2) corresponding to a total of 400 patients (median (InterQuartileRange) age at surgery 34 (26,47) years; 52% female) were included. In the year following ileocolonic resection, 189 (47%) patients displayed an i2a mRS and 211 (53%) an i2b. In the i2b group, we observed more male patients (56% versus 41%, p=0.01), more patients with previous ileocolonic resection (31% versus 21%, p=0.03) and temporary ileostomy (14% versus 6%, p=0.03) and an immunosuppressant or antiTNF therapy was more frequently initiated after endoscopy (42% versus 26%, p&amp;lt;0.01 and 36% versus 54%, p&amp;lt;0.01, respectively). The risk of clinical POR at 1, 3 and 5 years was 11% [6%-15%], 25% [18%-32%] and 36% [27%-43%] in the i2a group and 9% [5%-13%], 33% [26%-41%] and 47% [39%-56%] in the i2b group (p=0.63, p=0.12, et p=0.05 respectively). No significant difference was observed in terms of time to clinical POR (Hazard Ratio (HR)=1.27; Confidence Interval 95% [0.91,1.76]; p=0.16) (Figure 1) or surgical POR (HR=0.94; CI95% [0.44,2.00]; p=0.87). After exclusion of patients having initiated an immunosuppressant or a biologic in the 3 months after endoscopy (remaining cohort, n=361), no difference was observed in terms of clinical POR (HR=1.29 [0.92,1.80]; p=0.13) or surgical POR (HR=0.85 [0.39,1.84]; p=0.68). Conclusion In this individual patient data meta-analysis, no difference is observed between i2a and i2b mRS subcategories in terms of clinical, surgical or endoscopic POR. Limits of the mRS may explain this lack of predictive value.

P348 Top down versus step-up strategies to prevent postoperative recurrence in Crohn’s disease

Abstract Background The best management after ileocolonic resection is still unknown in Crohn’s disease (CD). We compared step-up and top-down approaches to prevent short and long-terms postoperative recurrences in CD patients. Methods From a comprehensive database, consecutive CD patients who underwent intestinal resection (2014–2021) were included. Top-down (biologics started within the first month after surgery) or step-up strategies (no biologic between surgery and colonoscopy at, 6 months) were performed with systematic colonoscopy at, 6 months and therapeutic escalation if Rutgeerts index was ≥i2a (endoscopic postoperative recurrence). Propensity score analysis (Inverse probability of treatment weighting) was applied for each comparison adjusted on the following parameters: gender, prior history of bowel resection, smoking habits, CD location, CD behaviour, resection length &amp;gt;, 30 cm, age and the number of biologics before surgery. Results Among, 115 CD patients, top-down was the most effective strategy to prevent endoscopic postoperative recurrence (Rutgeerts index ≥ i2a) (46.8% vs, 65.9%, p=0.042) and to achieve complete endoscopic remission (Rutgeerts index = i0) (45.3% vs, 19.3%, p=0.004) at, 6 months. The median time of follow-up (ending at the time first progression of bowel damage or last follow-up) was, 41.9 months [21.4–76.2]. We did not observe any significant difference between the two groups regarding clinical postoperative recurrence (hazard ratio (HR) = 0.86 [0.44–1.66], p=0.66) and progression of bowel damage (HR = 0.81 [0.63–1.06], p=0.12). Endoscopic postoperative recurrence (Rutgeerts index ≥ i2a) at, 6 months was associated with increased risk of clinical postoperative recurrence (HR = 1.97 [1.07–3.64], p, 0.029) and progression of bowel damage (HR = 3.33 [1.23–9.02], p=0.018). Among the subgroup without endoscopic postoperative recurrence (Rutgeerts index = i0 or i1) at, 6 months, the risks of clinical postoperative recurrence and progression of bowel damage were significantly improved in the top-down group compared to step-up (HR = 0.59 [0.37–0.94], p = 0.025) and HR = 0.73 [0.63–0.83], p&amp;lt;0.001, respectively). In contrast, when focusing on patients experiencing endoscopic postoperative recurrence (Rutgeerts index ≥ i2a) at, 6 months, top-down approach was associated with higher likelihood of clinical postoperative recurrence (HR = 1.92 [1.02–3.59], p = 0.042) and progression of bowel damage (HR = 1.58 [1.03–2.42], p = 0.035). Conclusion Top-down strategy should be preferred to step-up approach to prevent endoscopic postoperative recurrence as well as clinical postoperative recurrence and progression of bowel damage in most of the patients with Crohn’s disease after bowel resection.

P203 The performance of the Rutgeerts’ score, SES-CD, and MM-SES-CD for prediction of post-operative clinical recurrence in Crohn’s disease

Abstract Background Prevention of post-operative recurrence in Crohn’s disease (CD) is important to avoid further complications requiring additional surgeries. The Rutgeerts’s score is currently the gold standard assessment in clinical trials of post-operative CD. However, the Simplified Endoscopic Score for CD (SES-CD) has not been validated or used clinically in post-operative CD patients. The Modified Multiplier of the SES-CD (MM-SES-CD) is a novel internally validated tool that was developed to account for differences in items of the SES-CD and has not yet been validated in the setting of post-operative CD. The purpose of this study was to compare the SES-CD and MM-SES-CD scores with the Rutgeerts’ score for predicting clinical recurrence (CR) of post-operative CD. Methods This was a post-hoc analysis of data from the phase 3 PREVENT trial (ClinicalTrials.gov identifier: NCT01190839) of 208 participants who received infliximab or placebo. Receiver operating characteristic curve analyses to compare the Rutgeerts’, ileum SES-CD, and ileum MM-SES-CD scores at week 76 with CR at week 104. Multivariate logistic regression models evaluated cut-offs for the odds of achieving week 104 CR, after adjustment for confounders, including treatment allocation, disease duration, prior anti-TNF use, and concomitant immunomodulator use. CR was defined as CDAI score ≥200 and ≥70 point increase from baseline (or development of fistulas, abscesses, or treatment failure) and endoscopic recurrence, defined as Rutgeerts’ score ≥i2. Results The Rutgeerts’ score predicted week 104 CR at with fair accuracy [AUC: 0.74 (95% CI: 0.65–0.83)], which was similar to the SES-CD ileum score [AUC: 0.72 (95% CI: 0.64–0.80)] and the MM-SES-CD ileum score [AUC: 0.72 (95% CI: 0.63–0.80)]. Compared to various cut-offs by the other scores, the MM-SES-CD ileum score ≥26 at week 76 had the best ability to predict week 104 CR. Patients with a week 76 MM-SES-CD ileum score ≥26 were 4.17 times (95% CI: 1.90–9.12, p &amp;lt;0.001) more likely to have CR compared to those with a MM-SES-CD ileum score &amp;lt;26. Conclusion The ileal SES-CD and ileal MM-SES-CD perform similarly to the Rutgeerts’ score for predicting CR of post-operative CD. The MM-SES-CD threshold of ≥26 best predicted post-operative CR. Clinicians and trialists should consider the use of the MM-SES-CD in the assessment of post-operative CD given its performance and ability to capture colonic disease recurrence.

Specific Neuropeptide Expression in Crohn’s Disease Ileocolonic Resection Specimens Is Not Associated with Plexitis at the Ileal Margin or Postoperative Recurrence

BackgroundMyenteric plexitis is considered a risk factor for postoperative recurrence (POR) in Crohn’s disease (CD). The primary purpose of this study was to evaluate the association between neuropeptide Y (NPY), vasoactive intestinal peptide (VIP), and substance P (SP) expression and plexitis at the proximal resection margin. The secondary aim was to identify risk factors for POR. MethodsA retrospective, single-center study on CD patients who underwent ileocolonic resection (ICR) between January 2010 and December 2016 was conducted. The presence and severity of plexitis were evaluated by hematoxylin and eosin stain. Mast cells were highlighted by Giemsa stain. Immunohistochemistry was used to identify T lymphocytes and NPY-, VIP-, and SP-ergic neurons. Neuropeptide expression was quantified using image analysis. ResultsSeventy-nine patients were included. No association was detected between NPY, VIP, and SP expression and plexitis. Similarly, the number of involved inflammatory cells, T lymphocytes or mast cells was not correlated with neuropeptide expression. Smoking (hazard ratio [HR] 4.07; 95% confidence interval [CI] 2.08–7.94; p < 0.001), moderate (HR 3.68; 95%CI 1.06–12.73; p = 0.040), and severe myenteric plexitis (HR 7.36; 95%CI 1.12–48.30; p = 0.037) were independent risk factors for endoscopic POR, whereas smoking (HR 2.78; 95%CI 1.01–7.67; p = 0.049), severe myenteric plexitis (HR 20.03; 95%CI 1.09–368.28; p = 0.044), and involved ileal margin (HR 3.45; 95%CI 1.33–8.96; p = 0.011) for clinical POR. ConclusionsSmoking, moderate or severe myenteric plexitis, and involved ileal margin negatively affect POR in CD patients undergoing ICR. Submucosal and myenteric plexitis at the proximal resection margin is not related to the expression of specific neuropeptides.

Predictors of postoperative recurrence in a cohort of Tunisian patients with Crohn's disease.

Background:The aim of our study was to evaluate the frequency and risk factors of clinical postoperative recurrence in Tunisian patients with Crohn’s disease (CD).Methods:Clinical data of 86 patients with CD who underwent ileocolonic resection at University Hospital of Sahloul in Tunisia were retrospectively reviewed. Continuous data are expressed as median (interquartile range), and categorical data as frequencies and percentages. Multivariate Cox proportional hazard regression analysis was conducted to identify the risk factors of postoperative clinical recurrence.Results:A total of 86 patients with CD were included in this study. During follow-up, 21 patients (24.4%) had clinical recurrence. The cumulative clinical recurrence rate was 9.3% at 1 year and 20.9% at 5 years. In univariate analysis, predictive factors of postoperative clinical recurrence were active preoperative smoking (p = 0.008), ileal location of the disease (p = 0.01), active CD [Crohn’s Disease Activity Index (CDAI) > 150] (p = 0.04), duration of disease before first surgery <9.5 months (p = 0.027), and limited resection margins (<2 cm) from macroscopically diseased bowel (p = 0.005). In multivariate analysis, only smoking (p = 0.012), duration of disease before first surgery <9.5 months (p = 0.048), and limited resection margins (<2 cm) from macroscopically diseased bowel (p = 0.046) were confirmed to be independent factors of clinical relapse.Conclusion:Smoking, duration of disease before first surgery <9.5 months, and limited resection margins (<2 cm) from macroscopically diseased bowel were independent risk factors for clinical recurrence. Based on these factors, patients could be stratified in order to guide postoperative therapeutic options.