Postoperative Disease Recurrence Research Articles

Noninvasive Assessment of Postoperative Disease Recurrence in Crohn’s Disease: A Multicenter, Prospective Cohort Study on Behalf of the Italian Group for Inflammatory Bowel Disease

Colonoscopy (CS) is the gold standard to assess postoperative recurrence (POR) in Crohn's disease (CD). However, CS is invasive and may be poorly tolerated by patients. The aim of this study was to prospectively assess the diagnostic accuracy of a noninvasive approach in detecting POR, using the endoscopic Rutgeerts' score (RS) as the reference standard. Consecutive patients with CD who underwent ileo-cecal resection were prospectively enrolled in 3 referral Italian centers. Patients underwent CS and bowel ultrasound within 1 year of surgery. Uni- and multivariable analyses were used to assess the correlation between noninvasive parameters and endoscopic recurrence, defined by a RS ≥2. Ninety-one patients were enrolled. Sixty patients (66%) experienced endoscopic POR. The multivariable analysis identified bowel wall thickness (BWT) per 1-mm increase (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.21-4.89; P= .012), the presence of mesenteric lymph nodes (OR, 15.63; 95% CI, 1.48-164.54; P= .022), and fecal calprotectin (FC) values ≥50 mcg/g (OR, 8.58; 95% CI, 2.45-29.99; P < .001) as independent predictors for endoscopic recurrence. The presence of lymph nodes or the combination of BWT ≥3 mm and FC values ≥50 mcg/g correctly classified 56% and 75% of patients, with less than 5% of patients falsely classified as having endoscopic recurrence. Conversely, the combination of BWT <3 mm and FC <50 mcg/g correctly classified 74% of patients with only 4.5% of patients falsely classified as not having endoscopic recurrence. A noninvasive approach combining bowel ultrasound and FC can be used with confidence for detecting POR in patients with CD without the requirement for CS.

S61 Postoperative Ustekinumab Drug Levels and Disease Activity in Patients With Crohn’s Disease

Background: Ustekinumab is a biologic that targets and blocks the IL-12 and IL-23 receptors and effectively reduces clinical and endoscopic activity of Crohn’s Disease (CD) (1-3). Despite advances in CD treatment, including novel biologic therapies, surgical intervention is still common (4). Preventing postoperative recurrence of disease is critical to avoid subsequent procedures as these operations are expensive and invasive with risk for complications. Studies have previously evaluated for the association of postoperative drug levels, specifically of tumor necrosis factor inhibitors in relation to endoscopic disease recurrence (5-6). However, no study has been conducted to explore the association between postoperative ustekinumab levels and both endoscopic and clinical CD activity. Methods: This was a retrospective study of CD patients from a tertiary referral center that had an ustekinumab level taken postoperatively. Thirty-two total patients were identified. Ustekinumab drug levels were taken within 2 years postoperatively. Harvey-bradshaw index (HBI) was used to evaluate clinical disease activity and a combination of Rutgeerts’ and simple endoscopic score (SES) for Crohn’s Disease was used for endoscopic activity. Values for labs, clinical scores, and endoscopic scores were taken closest to surgery preoperatively with at least a one-month delay after surgery for postoperative values. Delta was the numeric difference between pre and postoperative measurements. Surgical procedures included small or large bowel resection, proctectomy, and fistulectomy. Patients were separated into groups depending on if their ustekinumab level was adequate, defined as greater than or equal to 4 μg/mL, or suboptimal, defined as below 4 μg/mL. All statistics were completed using built-in Excel functions for linear regression, linear correlation, and one-tailed t-test for unequal variance. P values of <0.05 and correlations above 0.8 were considered significant. Results: Average time drug levels taken postoperatively was 257 days. Postoperative hemoglobin levels were significantly higher in the adequate level group, 13.3 g/dL compared to 12.0 g/dL (P = 0.028). Hematocrit levels were also higher in the adequate ustekinumab level group, 40.5 versus 37.1 (P = 0.027). Clinically, patients with adequate ustekinumab levels had a greater change of their HBI score compared to preoperatively, delta HBI of -3 compared to 0.4 (P = 0.046). Only the suboptimal group showed a significant average decrease in endoscopic disease activity preoperatively to postoperatively, 85.7% to 37.5% (P = 0.029). No significant linear correlations were observed when comparing ustekinumab level to postoperative lab values, clinical scores, and endoscopic scores or their deltas. Conclusion(s): Adequate levels of ustekinumab yielded higher postoperative hemoglobin and hematocrit levels in addition to a greater reduction in HBI score. Only the suboptimal ustekinumab level group showed a significant reduction in average endoscopic disease activity compared to preoperative scores, which is consistent with findings that HBI does not necessarily correlate to endoscopic disease activity. The data suggests that adequate ustekinumab levels following CD surgery reduces the risk of anemia postoperatively and results in better clinical CD remission (HBI < 5) and response (delta HBI >=3). Future studies are needed to find the optimal ustekinumab levels both pre and postoperatively in order to maintain CD remission.

Kono-S Anastomosis in Crohn’s Disease: A Retrospective Study on Postoperative Morbidity and Disease Recurrence in Comparison to the Conventional Side-To-Side Anastomosis

The rates of postoperative recurrence following ileocecal resection due to Crohn's disease remain highly relevant. Despite this fact, while the Kono-S anastomosis technique initially demonstrated promising results, robust evidence is still lacking. This study aimed to analyze the short- and long-term outcomes of the Kono-S versus side-to-side anastomosis. A retrospective single-center study was performed including all patients who received an ileocecal resection between 1 January 2019 and 31 December 2021 at the Department of Surgery at the University Hospital of Wuerzburg. Patients who underwent conventional a side-to-side anastomosis were compared to those who received a Kono-S anastomosis. The short- and long-term outcomes were analyzed for all patients. Here, 29 patients who underwent a conventional side-to-side anastomosis and 22 patients who underwent a Kono-S anastomosis were included. No differences were observed regarding short-term postoperative outcomes. The disease recurrence rate postoperatively was numerically lower following the Kono-S anastomosis (median Rutgeert score of 1.7 versus 2.5), with a relevantly increased rate of patients in remission (17.2% versus 31.8%); however, neither of these results reached statistical significance. The Kono-S anastomosis method is safe and feasible and potentially decreases the severity of postoperative disease remission.

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.

Early Initiation of Antitumor Necrosis Factor Therapy Reduces Postoperative Recurrence of Crohn's Disease Following Ileocecal Resection.

Postoperative recurrence (POR) of Crohn's disease (CD) is common after surgical resection. We aimed to compare biologic type and timing for preventing POR in adult CD patients after ileocecal resection (ICR). We performed a retrospective cohort study of CD patients who underwent an ICR at 2 medical centers. Recurrence was defined by endoscopy (≥ i2b Rutgeerts score) or radiography (active inflammation in neoterminal ileum) and stratified by type and timing of postoperative prophylactic biologic within 12 weeks following an ICR (none, tumor necrosis factor antagonists [anti-TNF], vedolizumab, and ustekinumab). We identified 1037 patients with CD who underwent an ICR. Of 278 (26%) who received postoperative prophylaxis, 80% were placed on an anti-TNF agent (n = 223) followed by ustekinumab (n = 28, 10%) and vedolizumab (n = 27, 10%). Prophylaxis was initiated in 35% within 4 weeks following an ICR and in 65% within 4 to 12 weeks. After adjusting for factors associated with POR, compared with no biologic prophylaxis, the initiation of an anti-TNF agent within 4 weeks following an ICR was associated with a reduction in POR (adjusted hazard ratio, 0.61; 95% CI, 0.40-0.93). Prophylaxis after 4 weeks following an ICR or with vedolizumab or ustekinumab was not associated with a reduction in POR compared with those who did not receive prophylaxis. Early initiation of an anti-TNF agent within 4 weeks following an ICR was associated with a reduction in POR. Vedolizumab or ustekinumab, at any time following surgery, was not associated with a reduction in POR, although sample size was limited.

Early and late outcomes of a series of 255 patients with Crohn’s disease who underwent resection: 10 years of experience at a single referral center

Patients with Crohn's disease experience an increased risk of postoperative complications and disease recurrence. The aim of this study was to investigate the role of the risk factors in determining these outcomes and whether preoperative removal of some of these risk factors would optimize the results. We conducted a retrospective study analyzing a consecutive series of 255 patients who underwent surgical resection for Crohn's disease between 2010 and 2020. We considered short- and long-term endpoints, such as postoperative complications categorized according to the Clavien–Dindo classification and the appearance of surgical and endoscopic postoperative recurrence. Univariable and multivariable analyses showed that multiple and extensive localizations increased the incidence of postoperative complications (OR = 2.19; 95% CI 1.05–4.5; p = 0.035 and OR = 1.015; 95% CI 1.003–1.028; p = 0.017 for each cm of resected segment, respectively). Regarding theoretically modifiable factors, preoperative hypoalbuminemia (for each g/L reduction) increased the risk of complications with an OR = 1.1; 95% CI 1.02–1.12; p = 0.003. Preoperative steroid therapy exerted a similar effect, with an OR = 2.6; 95% CI 1.1–5.9; p = 0.018. Modifying these last two risk factors by improving the nutritional status or discontinuing steroid therapy significantly reduced complications.Microscopic positivity of the resection margins was a risk factor for surgical recurrence (OR = 8.7; 95% CI 1.9–40; p = 0.05). Based on the results of the present study, surgeons must examine modifiable risk factors, and careful preoperative tailored management may reduce postoperative complications and disease recurrence.

Treatment for postoperative recurrence of pancreatic cancer: a narrative review.

Patients with pancreatic cancer frequently develop postoperative disease recurrence, even after surgical resection with curative intent. Because of the heterogeneity of this patient population, phase III trials have never been conducted to establish a standard therapy for patients with post-surgical recurrence, and no uniform consensus based on high-level evidence exists as to which intervention might be the most appropriate. The aim of this review is to introduce globally popular treatment strategies for pancreatic cancer patients with postoperative recurrences. This is a narrative review, summarising the contemporary evidence and emerging studies with treatment for postoperative recurrence of pancreatic cancer. For patients with local recurrence alone, various therapeutic strategies have been attempted, including repeat surgical resection, chemoradiotherapy, and chemotherapy alone. Several studies have examined the outcomes of these therapies, but most are retrospective analyses of a small number of patients and statistically too underpowered to allow any solid recommendations to be made. Therefore, with the exception that there appears to be a potential benefit of repeat resection for isolated recurrences in the pancreatic remnant in a selected subgroup of patients, the patient outcomes remain dismal. In regard to the management of patients with distant recurrences, postoperative distant recurrences are generally not considered as being distinct from primary metastatic disease, and most patients with distant recurrence(s) with/without local tumor recurrence receive systemic chemotherapy as the standard therapy for metastatic disease; some studies have demonstrated a trend toward better survival outcomes in patients with a history of surgical resection than in those without a history of surgical resection. Although no uniform consensus based on high-level evidence exists, systemic chemotherapy has been used as the main treatment option, and some regimens have been demonstrated to offer a survival benefit. There is an urgent need for prospective trials to establish the most appropriate treatment strategies for this patients' population.

Vedolizumab may be an effective option for the treatment of postoperative recurrence of Crohn's disease.

The role of Vedolizumab (VDZ) as therapeutic option for the postoperative recurrence of Crohn's disease (CD) following ileocolonic resection is unknown. To assess the effectiveness of VDZ in this setting. All consecutive CD patients with a baseline colonoscopy at 6-12 months from the ileocolonic resection showing postoperative recurrence (Rutgeerts score ≥i2) and treated with VDZ after the baseline colonoscopy were extracted from the cohort of the Sicilian Network for Inflammatory Bowel Diseases (SN-IBD). The primary outcome was endoscopic success, assessed at the first colonoscopy following initiation of VDZ and defined as reduction of at least one point of Rutgeerts score. The secondary outcome was clinical failure, assessed at one year and at the end of follow-up. Fifty-eight patients were included (mean follow-up: 24.8±13.1 months). Endoscopic success was reported in 47.6% of patients. Clinical failure was reported in 19.0% of patients at one year, and in 32.8% of patients at the end of follow-up. A new resection was required in 7 patients (12.1%). VDZ may be an effective option for the treatment of postoperative recurrence of CD.

Deep Learning Analysis of Histologic Images from Intestinal Specimen Reveals Adipocyte Shrinkage and Mast Cell Infiltration to Predict Postoperative Crohn Disease

Most patients with Crohn disease (CD), a chronic inflammatory gastrointestinal disease, experience recurrence despite treatment, including surgical resection. However, methods for predicting recurrence remain unclear. This study aimed to predict postoperative recurrence of CD by computational analysis of histopathologic images and to extract histologic characteristics associated with recurrence. A total of 68 patients who underwent surgical resection of the intestine were included in this study and were categorized into two groups according to the presence or absence of postoperative disease recurrence within 2 years after surgery. Recurrence was defined using the CD Activity Index and the Rutgeerts score. Whole-slide images of surgical specimens were analyzed using deep learning model EfficientNet-b5, which achieved a highly accurate prediction of recurrence (area under the curve,0.995). Moreover, subserosal tissue images with adipose cells enabled highly accurate prediction. Adipose cell morphology showed significant between-group differences in adipose cell size, cell-to-cell distance, and cell flattening values. These findings suggest that adipocyte shrinkage is an important histologic characteristic associated with recurrence. Moreover, there was a significant between-group difference in the degree of mast cell infiltration in the subserosa. These findings show the importance of mesenteric adipose tissue in patient prognosis and CD pathophysiology. These findings also suggest that deep learning-based artificial intelligence enables the extraction of meaningful histologic features.

Mild neoterminal ileal post-operative recurrence of Crohn's disease conveys higher risk for severe endoscopic disease progression than isolated anastomotic lesions.

Retrospective cohort study of adult CD patients undergoing ileocolonic resection between 2009 and 2020. Patients with a post-operative ileocolonoscopy ≤18months from surgery and ≥1 subsequent ileocolonoscopy were included. Disease activity was assessed using the modified Rutgeerts' score (RS). Primary outcome was severe endoscopic progression, defined as i3 or i4 disease, on immediate subsequent ileocolonoscopy and during entire post-operative follow-up. Secondary outcome was surgical recurrence. One hundred and ninety-nine CD patients had an ileocolonoscopy ≤18months from surgery, index RS of i0-i2b and ≥1 subsequent ileocolonoscopy. At index ileocolonoscopy, 34.7% had i0 disease, 16.1% i1, 24.6% i2a and 24.6% i2b. On multivariable logistic regression, i2b disease was associated with severe endoscopic progression compared to i0 or i1 (aOR 5.53; P<0.001) and i2a disease patients (aOR 2.63; P=0.03). However, i2a disease did not confer increased risk compared to i0 or i1 disease (P=0.09). Furthermore, i2b patients experienced severe endoscopic progression significantly earlier than i0 or i1 disease (aHR 4.68; P<0.001), whereas i2a disease did not differ from i0 or i1 disease (P=0.25). Surgical recurrence was not associated with index RS i0-i2b (P=0.86). Post-operative ileal disease recurrence, not isolated anastomotic inflammation, confers increased risk for severe endoscopic disease progression. Location of CD recurrence may impact optimal management strategies.

Imaging of the Postoperative Temporal Bone.

Evaluation of the postoperative temporal bone can be difficult given the complex anatomy of this region and the myriad surgical approaches for management of a variety of conditions. This article provides an understanding of common postsurgical changes of the temporal bone and their typical imaging appearances. Ultimately, greater radiologist knowledge of postoperative temporal bone imaging findings will help to serve patients and referring clinicians with prompt diagnosis and recognition of expected postintervention changes compared with postoperative complications and/or disease recurrence.

P512 Vedolizumab is effective in the prevention and treatment of postoperative recurrence in patients with Crohn′s disease

Abstract Background Vedolizumab (VDZ), an anti-integrin monoclonal antibody has demonstrated its efficacy in inducing and maintaining response in patients with luminal Crohn`s disease (CD). Postoperative recurrence (POR) affects over half of the patients with CD and currently, majority of these patients undergo surgery due to primary or secondary failure of anti-tumor necrosis factor (antiTNF) biologics. Thus, data on efficacy of other agents in this setting are needed. Considering the slow onset of action of VDZ together with its favorable safety profile in older and co-morbid patients, VDZ would represent a good candidate for preventing and treating POR but the data on its efficacy in this specific clinical situation are scarce. Therefore, the aim of this study was to evaluate the efficacy of VDZ in preventing and treating of Crohn`s disease postoperative recurrence. Methods In this retrospective single-center cohort study, we included all patients with CD treated with VDZ between May 2015 and August 2020. Patients who started with VDZ immediately postoperatively or continued from the pre-operative period (prevention of POR) or patients who started VDZ because of clinical or endoscopic POR (treatment of POR) with a minimal follow-up of one year were eligible for further analysis. The effect of VDZ was determined by Harvey-Bradshaw Index ≤ 4 in case of prevention of POR, or as any decrease of 3 or more points in case of treatment of POR. Endoscopic response was evaluated by Rutgeerts` score as any decrease of the score. All patients underwent the colonoscopy at 6 months postoperatively and further follow-up colonoscopy one year after treatment adjustment. Results In the defined period, a total of 54 patients with Crohn`s disease were treated with VDZ. Of these 54 patients, sixteen (11 women; median age 57 years, range 25–75) receive VDZ for prevention (6) or treatment (10) of postoperative recurrence. Six patients received first-line VDZ due to high risk profile for systemic biologics (age and/or co-morbidities), the remaining ten patients all had previously failed at least one anti-tumor necrosis factor biologic agent. During the median follow-up of 24 months (range 12 to 70), thirteen patients (81%) had clinical response or achieved remission, eleven (69%) had endoscopic response. Three patients with no response had to change the treatment to another biologic. Out thirteen responders, seven (54%) necessitated intensification of dosing regimen to every 4 or 6 weeks in order to achieve clinical and/or endoscopic response. Conclusion Vedolizumab is effective in preventing and treating of Crohn`s disease postoperative recurrence in a difficult-to-treat population of patients.

Signaling pathways and their potential therapeutic utility in esophageal squamous cell carcinoma.

Esophageal cancer is a complex gastrointestinal malignancy with an extremely poor outcome. Approximately 80% of cases of this malignancy in Asian countries including India are of squamous cell origin, termed Esophageal Squamous Cell Carcinoma (ESCC).The five-year survival rate in ESCC patients is less than 20%.Neo-adjuvant chemo-radiotherapy (NACRT) followed by surgical resection remains the major therapeutic strategy for patients with operable ESCC. However, resistance to NACRT and local recurrence after initial treatment are the leading cause of dismal outcomes in these patients. Therefore, an alternative strategy to promote response to the therapy and reduce the post-operative disease recurrence is highly needed. At the molecular level, wide variations have been observed in tumor characteristics among different populations, nevertheless, several common molecular features have been identified which orchestrate disease progression and clinical outcome in the malignancy. Therefore, determination of candidate molecular pathways for targeted therapy remains the mainstream idea of focus in ESCC research. In this review, we have discussed the key signaling pathways associated with ESCC, i.e., Notch, Wnt, and Nrf2 pathways, and their crosstalk during disease progression. We further discuss the recent developments of novel agents to target these pathways in the context of targetedcancer therapy. In-depth research of the signaling pathways, gene signatures, and a combinatorial approach may help in discovering targeted therapy for ESCC.

Circulating metabolites as a concept beyond tumor biology determining disease recurrence after resection of colorectal liver metastasis.

Micro-metastatic growth is considered the main source of early cancer recurrence. Nutritional and microenvironmental components are increasingly recognized to play a significant role in the liver. We explored the predictive potential of preoperative plasma metabolites for postoperative disease recurrence in colorectal cancer liver metastasis (CRCLM) patients. All included patients (n=71) had undergone R0 liver resection for colorectal cancer liver metastasis in the years between 2012 and 2018. Preoperative blood samples were collected and assessed for 180 metabolites using a preconfigured mass-spectrometry kit (Biocrates Absolute IDQ p180 kit). Postoperative disease-free (DFS) and overall survival (OS) were prospectively recorded. Patients that recurred within 6 months after surgery were defined as "high-risk" and, subsequently, a three-metabolite model was created which can assess DFS in our collective. Multiple lysophosphatidylcholines (lysoPCs) and phosphatidylcholines (PCs) significantly predicted disease recurrence within 6 months (strongest: PC aa C36:1 AUC=0.83, p=0.003, PC ae C34:0 AUC=0.83, p=0.004 and lysoPC a C18:1 AUC=0.8, p=0.006). High-risk patients had a median DFS of 183 days versus 522 days in low-risk population (p=0.016, HR=1.98 95% CI 1.16-4.35) with a 6 months recurrence rate of 47.6% versus 4.7%, outperforming routine predictors of oncological outcome. Circulating metabolites identified CRCLM patients at highest risk for 6 months disease recurrence after surgery. Our data also suggests that circulating metabolites might play a significant pathophysiological role in micro-metastatic growth and concomitant early tumor recurrences after liver resection. However, the clinical applicability and performance of this proposed metabolomic concept needs to be independently validated in future studies.

Surgical Strategies to Reduce Postoperative Recurrence of Crohn's Disease After Ileocolic Resection.

Postoperative recurrence after ileocaecal resection for fibrostenotic terminal ileal Crohn's disease is a significant issue for patients as it can result in symptom recurrence and requirement for further surgery. There are very few modifiable factors, aside from smoking cessation, that can reduce the risk of postoperative recurrence. Until relatively recently, the surgical technique used for resection and anastomosis had little or no impact on postoperative recurrence rates. Novel surgical techniques such as the Kono-S anastomosis and extended mesenteric excision have shown promise as ways to reduce postoperative recurrence rates. This manuscript will review and discuss the evidence regarding a range of surgical techniques and their potential role in reducing disease recurrence. Some of the techniques have been shown to be associated with significant benefits for patients and have already been integrated into the routine clinical practice of some surgeons, while other techniques remain under investigation. Current techniques such as resection of the mesentery close to the intestine and stapled side to side anastomosis are being challenged. It is looking more likely that surgeons will have a major role to play when it comes to reducing recurrence rates for patients undergoing ileocaecal resection for Crohn's disease.

Efficacy of Supratarsal Triamcinolone Injection versus Dexamethasone in Recalcitrant Vernal Keratoconjunctivitis

Aim: To determine the effectiveness of supratarsal triamcinolone injection versus dexamethasone in recalcitrant vernal keratoconjunctivitis. Study Design: Prospective/randomized study Place and Duration of Study: Department of Ophthalmology, Lorallai Medical College, Loralai from 1st October 2020 to 31st March 2021. Methods: Fifty patients (100 eyes) of both genders and age between 12-40 years were enrolled. Detailed demographics of enrolled cases age, sex and body mass index were recorded after taking informed written consent. All patients had recalcitrant vernal keratoconjunctivitis. Patients were equally divided into 2-groups. Group I had 25 patients and received 20mg of supratarsal triamcinolone injection in both eyes and group II with 25 patients received 2mg of dexamethasone in their eyes. Postoperative effectiveness, complications and recurrence of disease was observed and compared among both groups. Results: There were 15 (60%) males and 10 (40%) females in group I with mean age 18.14±6.34 years while in group II, 15 (60%) males and 10 (40%) females with mean age was 17.68±4.54 years. Palprebral vernal keratoconjunctivitis was found in 36 eyes (10 patients of group I and 8 patients of group II) and Mixed vernal keratoconjunctivitis in 64 eyes (15 patients of group I and 17 patients of group II). Symptoms were itching,photophobia, lacrimation and pain. Conjunctival hyperemia, giant papillae and limbal infiltrate were the most common signs observed. Post operatively effectiveness among group I and II was (100% vs 92%) without any complication. Recurrence rate of vernal keratoconjunctivitis in group I was lower 4% as compared to group II 10%. Conclusion: The use of supratarsal triamcinolone injection in patients of recalcitrant vernal keratoconjunctivitis was effective and safest method as compared to dexamethasone in terms of less recurrence and high rate of efficacy. Keywords: Supratarsal triamcinolone, Dexamethasone, Vernal keratoconjunctivitis, Effectiveness, Recurrence

Anatomic-hemodynamical types of recurrence of the lower extremities varicose disease

Objective. To improve the results of treatment in patients with postoperative recurrence of varicose disease of the lower extremities with the help of studying of peculiarities of disorders in regional venous hemodynamics and determination of anatomic-hemodynamic types of the disease.&#x0D; Materials and methods. There were examined 85 patients with postoperative recurrence of varicose disease of the lower extremities. Ultrasonic duplex scanning of veins was performed on apparatus «EnVisor», manufactured by «Philips» (Holland) using a multifrequency linear sensor with the 12 - 5 MHz frequency for subcutaneous veins and a convex sensor with the 5 - 2 MHz frequency - for deep veins.&#x0D; Results. There were delineated 8 anatomic-hemodynamical types of recurrences of varicose disease of the lower extremities. The investigation conducted have permitted to systematize the causes and signs of the disease. Objective criteria for prognostication of the varicose disease of the lower extremities recurrence may be applied for optimization of volume of primary surgical intervention and prophylaxis of its complications.&#x0D; Conclusion. The main causes of the recurrence development in varicose disease of the lower extremities are tactical and technical mistakes of surgeons during performance of primary surgical interventions in patients, suffering varicose disease of the lower extremities. Studying of peculiarities in development of recurrence of varicose disease of the lower extremities permits to elaborate the practical anatomic-hemodynamical classification, which systematizes the main causes of the varicose disease recurrence and constitutes the base for the reoperations tactics elaboration.

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

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

Thiopurines are superior to mesalamine for preventing postoperative recurrence in patients with Crohn's disease and two or more risk factors.

To confirm the hypothesis that thiopurines are better than mesalamine for preventing postoperative recurrence of Crohn's disease (CD) in patients with more than two risk factors. In total 87 consecutive CD patients who underwent curative ileocolonic resection and ileocolic anastomosis were retrospectively recruited, including 43 prescribed with thiopurines and 44 with mesalamine after surgery. Four risk factors were predefined for subgroup analyses: smoking, penetrating disease, perianal disease and previous resection. End-points included clinical (Crohn's disease activity index >200) and endoscopic recurrence (Rutgeerts score ≥i2) within 52 weeks. There were no significant differences in clinical (37.2% vs 54.5%, P=0.105) and endoscopic recurrence (55.8% vs 75.0%, P=0.060) between the thiopurines and mesalamine groups by week 52. In the subgroup analysis of patients with two or more risk factors, clinical (35.7% vs 81.8%, P=0.042) and endoscopic recurrence (64.3% vs 100%, P= 0.046) were less frequent in the thiopurine group than the mesalamine group. With one additional risk factor, the risk of endoscopic recurrence in the thiopurines group increased by 2.201-fold (95% confidence interval [CI] 1.178-4.115), adjusted for treatment intervention. While the risk of clinical and endoscopic recurrence in patients treated with mesalamine increased by 3.383-fold and 5.884-fold (95% CI 1.260-9.081 and 1.598-21.662). Three patients treated with thiopurines withdrew for adverse events. Thiopurines may be superior to mesalamine for preventing postoperative recurrence of CD in patients with two or more risk factors. Caution is needed in light of the adverse events caused by thiopurines.

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