Resection For Crohn Research Articles

Managing Crohn’s Disease Postoperative Recurrence Beyond Prophylaxis: A Comprehensive Review with Meta-Analysis

Background and Aims: Postoperative recurrence in Crohn’s disease remains a significant clinical challenge, with high recurrence rates despite advancements in medical therapy. This study aims to evaluate the efficacy of various treatments for managing postoperative recurrence following ileocolonic resection in Crohn’s disease. Methods: A comprehensive search of PubMed, Cochrane, and Scopus databases was performed to identify studies reporting on the therapeutic management of postoperative recurrence in Crohn’s disease. Studies encompassing patients with an endoscopic Rutgeerts score of at least I2 were included. Results: Ustekinumab showed promise, achieving significant endoscopic and clinical success in difficult-to-treat patients. Anti-TNF agents demonstrated superior endoscopic and clinical remission rates compared to mesalamine and azathioprine. Retreatment with anti-TNF therapy remained effective even after preoperative failure. Thalidomide showed efficacy in refractory Crohn’s disease, but carries significant toxicity risks, necessitating careful patient selection and monitoring. Combination therapies and non-pharmacologic strategies like enteral nutrition offer additional options, though patient compliance remains challenging. Conclusions: Personalized treatment plans based on individual risk factors and biomarkers are crucial. Infliximab is recommended as the first-line treatment, with ustekinumab and vedolizumab as alternatives in case of anti-TNF failure or intolerance. Early intervention, patient education, and ongoing evaluation are essential for optimizing long-term outcomes in managing postoperative recurrence in Crohn’s disease.

FP4.5 - An assessment of web-based patient information on bowel resection in Crohn's disease

Abstract Aim Most patients with Crohn’s disease (CD) have at least one bowel resection during their lifetime. 80% of patients with terminal ileal CD (the most common phenotype) will require a bowel resection at some point. Patients considering a bowel resection for CD will likely look for information online, as is common practice among patients with chronic illnesses. The aim of this study is to assess the quality and readability of web-based patient information on bowel resection for CD. Methods GoogleTM was searched using pre-defined search terms that were developed with input from patient experts. For each term, results from the first two pages were screened for eligibility. Patient-focused websites on bowel resection for CD were included. The quality of the information was assessed using the DISCERN tool, and the readability with the Flesch-Kincaid ease of readability (FK) score. Results Of the 118 sources identified, 91 were excluded and 27 sources were analysed. A third (n=10) did not discuss the different types of resections. Ileocaecal resection (the most commonly performed resection) was described in 7 sources. Discussion of management post-resection (n=7) and of lifestyle changes (n=12) were sparse. There were some instances of factually incorrect information. The mean DISCERN score was 3.2±0.31 (range 1-5), indicating moderate quality information. The mean FK score was 49.9 (corresponding to “difficult to read”). Conclusion Professional bodies and clinicians should work alongside patient groups to develop online sources which are in appropriate lay language and evidence-based, and suit patients’ informational needs to aid patient decision making.

Effect of mesenteric sparing or extended resection in primary ileocolic resection for Crohn's disease on postoperative endoscopic recurrence (SPICY): an international, randomised controlled trial

Retrospective research suggests that excision of the affected mesentery can improve outcomes after an ileocoecal resection in Crohn's disease. However, prospective data from randomised controlled trials are scarce. We aimed to compare rates of postoperative recurrence in patients with Crohn's disease who underwent extended mesenteric resection. This international, randomised controlled trial was done in six hospitals and tertiary care centres in the Netherlands and Italy. Eligible patients were aged 16 years or older and had Crohn's disease that was previously confirmed by endoscopy in the terminal ileum or ileocolic region (L1 or L3 disease), with an imaging update in the past 3 months (ultrasound, MRI, or CT enterography). Eligible patients were scheduled to undergo primary ileocolic resection with ileocolic anastomosis. Enrolled patients were assigned by use of simple random allocation (1:1) to either extended mesenteric resection (intervention) or conventional mesenteric sparing resection (control). The primary endpoint was endoscopic recurrence 6 months after surgery. Analyses were done in all patients with primary endpoint data, excluding those who had no anastomosis, a postoperative diagnosis other than Crohn's disease, or withdrew consent. This trial was registered with ClinicalTrials.gov, NCT04538638. Between Feb 19, 2020, and April 24, 2023, we assessed 217 patients for eligibility. 78 patients were excluded due to failure to meet the inclusion criteria or refusal to participate. 139 patients were enrolled and randomly assigned to either extended mesenteric resection (n=71) or mesenteric sparing resection (n=68). All 139 patients underwent surgery. Six patients were excluded after random assignment due to withdrawal of consent (n=2), postoperative diagnosis other than Crohn's disease (n=2) and no anastomosis performed (in case of a stoma; n=2). Two patients were lost to follow-up, and two more patients deviated from the protocol by undergoing investigations other than endoscopy 6 months after. 133 patients were included in the baseline analysis (67 in the extended resection group and 66 in the sparing resection group) of whom 57 (43%) were male. Baseline characteristics were similar between the groups, and median patient age was 36 years (IQR 25-54). 131 patients were analysed for the primary outcome. There was no difference between groups in the rate of endoscopic recurrence at 6 months after surgery (28 [42%] of 66 patients in the extended mesenteric resection group vs 28 [43%] of 65 patients in the mesenteric sparing resection group, relative risk 0·985, 95% CI 0·663-1·464; p=1·0). Five (8%) of 66 patients in the extended mesenteric resection group had anastomotic leakage within the 30 days after surgery, as did one (2%) of 65 in the mesenteric sparing group. Postoperative complications of Clavien-Dindo grade IIIa or higher were reported in seven (11%) patients in the mesenteric resection group and five (8%) in the mesenteric sparing group. Extended mesenteric resection was not superior to conventional resection with regard to endoscopic Crohn's disease recurrence. These data support the guideline-recommended mesenteric sparing approach. Topconsortia voor Kennis en Innovatie-Topsector Life Sciences & Health.

Impact of Kono-S anastomosis on quality of life after ileocolic resection in Crohn's disease: an analysis from the SuPREMe-CD trial.

Crohn's disease has debilitating effects on patients' quality of life. Currently, there are limited data on the effect of anastomotic configuration on health-related quality of life after ileocaecal resection for Crohn's disease. This study aimed to assess the impact of Kono-S anastomosis on quality of life after ileocolic resection, compared to the conventional side-to-side anastomosis. Patients with primary or recurrent Crohn's disease participating in the ongoing SuPREMe-CD trial were interviewed about quality of life using the Inflammatory Bowel Disease Questionnaire (IBDQ). The primary endpoint was disease-specific quality of life, assessed with IBDQ. Secondary outcomes were quality of life related to bowel symptoms, systemic symptoms, social function and emotional function. Of the 94 patients included, 51 (54%) received the conventional side-to-side anastomosis and 43 (46%) the Kono-S anastomosis. Demographics were comparable between the two groups. The IBDQ was assessed at a mean follow-up of 54.0 ± 18.7 months from surgical intervention. The mean total IBDQ score was 155.1 ± 28.07 in the conventional group and 163.8 ± 25.23 in the Kono-S group (P = 0.11). When considering bowel symptoms and social function, mean scores were 50.7 and 23.5 in the conventional group, and 56.3 and 26.5 in the Kono-S group (P = 0.002 and P = 0.02, respectively). Kono-S anastomosis was independently associated with improved quality of life regarding bowel symptoms (P = 0.006) and social function (P = 0.03) after correcting for other confounding factors on linear regression analysis. Compared to conventional side-to-side anastomosis, patients with Kono-S anastomosis presented significantly better bowel symptoms and social function scores at 54 months after surgery.

Intestinal resection in Crohn's disease. Impact of timing of surgery on postoperative complications and recurrence. retrospective cohort study.

Crohn's disease is a chronic inflammatory disorder which involves mainly the gut. It poses a continuous challenge for health care due to the lack of effective medical therapies. Given the situation of this refractory disease, surgery is indicated. However, the optimal moment to perform it stills unknown. Data from 38 patients who underwent elective ileal resection because of Crohn's disease between years 2019 and 2022 were collected. Early postoperative morbimortality, ileostomy rates, postoperative complications rates and postoperative recurrence rates were retrieved.

Stapled versus hand-sewn anastomoses after bowel resection in patients with crohn disease

BackgroundAnastomosis configuration is an essential step in treatment to restore continuity of the gastrointestinal tract following bowel resection in patients with Crohn’s disease (CD). However, the association between anastomotic type and surgical outcome remains controversial. This retrospective study aimed to compare early postoperative complications and surgical outcome between stapler and handsewn anastomosis after bowel resection in Crohn’s disease.MethodsBetween 2001 and 2018, a total of 339 CD patients underwent bowel resection with anastomosis. Patient characteristics, intraoperative data, early postoperative complications, and outcomes were analyzed and compared between two groups of patients. Group 1 consisted of patients with stapler anastomosis and group 2 with handsewn anastomosis.ResultsNo significant difference was found in the incidence of postoperative surgical complications between the stapler and handsewn anastomosis groups (25% versus 24.4%, p = 1.000). Reoperation for complications and postoperative hospital stay were similar between the two groups.ConclusionOur analysis showed that there were no differences in anastomotic leak, nor postoperative complications, mortality, reoperation for operative complications, or postoperative hospital stay between the stapler anastomosis and handsewn anastomosis groups.

Surgically-relevant quality of life thresholds for the Short Inflammatory Bowel Disease Questionnaire in Crohn’s disease

Background or PurposeDespite interest in patient-reported outcome measures to track progression in Crohn’s disease, frameworks to apply these questionnaires in the preoperative setting are lacking. Using the short inflammatory bowel disease questionnaire (sIBDQ), this study aimed to describe interpretable quality of life thresholds and examine potential associations with future bowel resection in Crohn’s disease. MethodsAdult Crohn’s disease patients completing an sIBDQ at a clinic visit between 2020-2022 were eligible. A stoplight framework was adopted for sIBDQ scores, including a ‘Resection Red zone’ suggesting poor quality of life that may benefit from discussions about surgery as well as a ‘Nonoperative Green’ zone. Thresholds were identified with both anchor- and distribution-based methods using receiver operating characteristic curve analysis and subgroup percentile scores, respectively. To quantify associations between sIBDQ scores and subsequent bowel resection, multivariable logistic regression models were fit with covariates of age, sex, body mass index, medications, disease pattern and location, resection history, and the Harvey Bradshaw Index. Incremental discriminatory value of the sIBDQ beyond clinical factors was assessed through area under the receiver operating characteristics curve (AUC) with an internal validation through bootstrap resampling. ResultsOf 2003 included patients, 102 underwent Crohn’s-related bowel resection. The sIBDQ Nonoperative Green zone threshold ranged from 61 to 64 and the Resection Red zone from 36 to 38. When adjusting for clinical covariates, a worse sIBDQ score was associated with greater odds of subsequent 90-day bowel resection when considered as a one-point (OR [95% CI], 1.05 [1.03-1.07]) or five-point change (OR [95% CI], 1.25 [1.13-1.40]). Inclusion of the sIBDQ modestly improved discriminative performance (AUC [95% CI] 0.85 [0.85 – 0.86]) relative to models that included only demographics (0.57 [0.57 – 0.58]) or demographics with clinical covariates (0.83 [0.83 – 0.84]). Discussion or ConclusionIn the decision-making process for bowel resection, disease-specific patient-reported outcome measures may be useful to identify Crohn’s disease patients with poor quality of life and promote shared understanding of personalized burden.

Predictive Factors of Non-Inflammatory Small Bowel Obstruction After Bowel Resection in Crohn's Patients.

The aim of the study was to investigate the risk factors associated with the development of small bowel obstruction (SBO) in Crohn's disease (CD) after small bowel resection (SBR) that are not due to active/recurrent inflammation. We conducted a retrospective cohort study of patients who had SBR for active or complicated CD. Abstracted data included demographics, phenotype, therapies for CD, endoscopic disease recurrence, and several surgical variables. The primary outcome was the development of non-inflammatory SBO (NI-SBO) within 5 years after SBR. A total of 335 patients were included. The cumulative rates of NI-SBO at 6 months, 1 year, and 5 years were 5 (1.5%), 8 (2.4%), and 29 (8.9%), respectively. Variables associated with the development of NI-SBO were active macroscopic or microscopic inflammation in the surgical margins (13 (56%) vs. 65 (27%), P = 0.004), open resection (vs. laparoscopic resection) (12 (41.4%) vs. 60 (19.5%), P = 0.0006) and a higher median number of previous resections (2 (interquartile range (IQR) 2 - 3) vs. 1 (IQR 1 - 2), P = 0.0002). Only 21% of patients who developed NI-SBO required surgical intervention. The incidence of NI-SBO after SBR in CD is low and associated with inflammation at the margins of the resected bowel, previous bowel resections, and an open laparotomy approach. Most NI-SBOs resolve with medical management.

OP20 Postoperative endoscopic recurrence after resection of Crohn’s terminal ileitis with Kono-S or side-to-side functional end anastomosis: results of a Multicenter Prospective Randomized Trial

Abstract Background A novel anastomosis (Kono-S) was described in 2003 in Crohn’s disease. Subsequent observations have suggested that this anastomosis is associated with lower endoscopic and surgical recurrence rates. The purpose of this study was to compare the endoscopic recurrence between the Kono-S and the side-to-side functional end anastomosis at 3-6 months after resection of Crohn’s terminal ileitis. Methods This was a prospective multi-center randomized trial conducted at eight international centers. Patients with Crohn’s terminal ileitis requiring elective ileocecal resection were randomized to a Kono-S (Group1) or a side-to-side functional end (Group2) anastomosis (Image1). Patients were discharged on no biologicals. Exclusion criteria included age (<18), pregnancy, recurrent or multisite Crohn’s disease, and need of postoperative treatment with biologicals. Data were collected prior to and during surgery, daily after surgery until discharge, at 30 days post-op, and at 3-6 months colonoscopy. Participating surgeons were instructed in the Kono-S technique through videos. Disease clinical activity was measured by Harvey Bradshaw Index (HBI). Endoscopic remission/recurrence was graded with the modified Rutgeerts score: endoscopic remission was defined as a Rutgeerts score of 0, 1, or 2a, and a Rutgeerts score of 2b or higher was considered a recurrence. All study sites had Institutional Review Board approval, ClinicalTrial.gov # NCT03256240. Results We enrolled 288 Crohn’s patients (50.7% female) with a median age of 34 (18-81). 154 patients were randomized to Group 1 (Kono-S) and 134 to Group 2 (Side-to-Side). 30 days follow-up was completed on 278 (96.9%) patients. The Kono-S group had a higher percentage of past smokers (57 vs.30, p = 0.007) and current smokers (33 vs.12, p = 0.004). The mean operative time was 22 minutes longer in the Kono-S group (154 vs.132 minutes; p = 0.386). There was no mortality. 233 (81%) patients underwent a colonoscopy at 3-6 months. There was no significant difference between the two groups in terms of endoscopic recurrence (p = 0.883) and HBI (p = 0.109) or in recurrence-free survival (Log Rank Mantel-Cox test p = 0.256) (Table 1). On multivariable analysis, current smokers had significantly higher odds for endoscopic recurrence at 3-6 months (OR= 2.80, [95% CI =1.10 - 6.92], p = 0.029). Conclusion Kono-S and Side-to-side anastomoses have similar endoscopic recurrence rates at 3-6 months. Independently of surgical techniques, smokers had a significantly higher rate of endoscopic recurrence at 3-6 months after surgery.

Hospital Surgical Volume-Outcome Relationship of Postoperative Morbidity for Ileocolic Resection in Crohn's Disease: A French Nationwide Study of 4205 Patients.

Despite the development of medical therapy, nearly 50% of patients with Crohn's disease [CD] undergo surgery during their lifetime. Several studies have suggested some risk factors for postoperative morbidity [POM] after ileocolic resection [ICR]. However, the impact of surgical hospital volume on POM in CD has not been extensively studied. This study aimed to assess the impact of surgical hospital volume on POM after ICR for CD. All patients with CD who underwent ICR in France between 2013 and 2022 were identified in the French Database, Programme de Médicalisation des Systèmes d'Information. Using the Chi-square automatic interaction detector, we determined the cut-off value to split high-surgical-volume [≥6 ICRs/year] and low-surgical-volume centres [<6 ICRs/year]. The primary outcome was the evaluation of major POM during hospitalization. POM was evaluated according to the surgical volume centre. The Elixhauser comorbidity index [ECI] was used to categorize the comorbidities of patients. A total of 4205 patients were identified, and the major POM during hospitalization was significantly [p = 0.0004] lower in the high-surgical-volume [6.2%] compared to low-surgical-volume centres [9.1%]. After multivariate analysis, independent factors associated with major POM were surgical hospital volume [p = 0.024], male sex [p = 0.029], ECI ≥ 1 [p < 0.001], and minor POM [p < 0.001]. Major POM after ICR for CD is closely associated with surgical hospital volume. Centralization of surgery for CD is desirable, especially in patients with major comorbidities.

Clinical Predictors of Early and Late Endoscopic Recurrence Following Ileocolonic Resection in Crohn's Disease.

Multiple factors are suggested to place Crohn's disease patients at risk of recurrence after ileocolic resection with conflicting associations. We aimed to identify clinical predictors of recurrence at first [early] and further [late] postoperative colonoscopy. Crohn's disease patients undergoing ileocolic resection were prospectively recruited at six North American centres. Clinical data were collected and endoscopic recurrence was defined as Rutgeerts score ≥i2. A multivariable model was fitted to analyse variables independently associated with recurrence. A total of 365 patients undergoing 674 postoperative colonoscopies were included with a median age of 32 years, 189 [51.8%] were male, and 37 [10.1%] were non-Whites. Postoperatively, 133 [36.4%] used anti-tumour necrosis factor [anti-TNF] and 30 [8.2%] were smokers. At first colonoscopy, 109 [29.9%] had recurrence. Male gender (odds ratio [OR] = 1.95, 95% confidence interval [CI] 1.12-3.40), non-White ethnicity [OR = 2.48, 95% CI 1.09-5.63], longer interval between surgery and colonoscopy [OR = 1.09, 95% CI 1.002-1.18], and postoperative smoking [OR = 2.78, 95% CI 1.16-6.67] were associated with recurrence, while prophylactic anti-TNF reduced the risk [OR = 0.28, 95% CI 0.14-0.55]. Postoperative anti-TNF prophylaxis had a protective effect on anti-TNF experienced patients but not on anti-TNF naïve patients. Among patients without recurrence at first colonoscopy, Rutgeerts score i1 was associated with subsequent recurrence [OR = 4.43, 95% CI 1.73-11.35]. We identified independent clinical predictors of early and late Crohn's disease postoperative endoscopic recurrence. Clinical factors traditionally used for risk stratification failed to predict recurrence and need to be revised.

Prognostic Value of the Modified Rutgeerts Score for Long-Term Outcomes After Primary Ileocecal Resection in Crohn's Disease.

The prognostic value of the modified Rutgeerts score (mRS) in patients with Crohn's disease (CD) needs to be further elucidated. This study assessed the prognostic value of the mRS for long-term outcomes after primary ileocecal resection in patients with CD. Patients with CD after primary ileocecal resection with an available mRS at first postoperative ileocolonoscopy (index mRS) were retrospectively included. The primary outcome was surgical recurrence. Secondary outcomes were clinical recurrence and progression to severe endoscopic recurrence (≥i3). Cox proportional hazard models were used to assess the association between index mRS and outcomes. Six hundred fifty-two patients were included (mean follow-up: 6.4 years, SD: 4.6). Surgical recurrence rates were 7.7%, 5.3%, 12.9%, 19.1%, 28.8%, 47.8% for index mRS i0, i1, i2a, i2b, i3, and i4, respectively. Clinical recurrence occurred in 42.2% (i0), 53.7% (i1), 58.5% (i2a), 80.2% (i2b), 79.4% (i3), and 95.3% (i4) of patients. Progression to severe endoscopic recurrence occurred in 21.1% (i0), 33.9% (i1), 26.8% (i2a), and 33.3% (i2b) of patients. An index mRS of i2b (adjusted hazard ratio [aHR] 3.0; 1.5-5.6), i3 (aHR 4.0; 2.0-7.9) and i4 (aHR 8.0; 4.0-16.0) were associated with surgical recurrence. An index mRS of i1 (aHR 1.7; 1.2-2.4), i2a (aHR 1.7; 1.2-2.4), i2b (aHR 4.4; 3.2-6.0), i3 (aHR 3.6; 2.5-5.2), and i4 (aHR 7.3; 4.8-10.9) were associated with clinical recurrence. An index mRS of i1 (aHR 2.0; 1.1-3.7) or i2b (aHR 2.5; 1.4-4.6) was associated with progression to severe endoscopic recurrence. The increasing mRS corresponds closely with the risk of surgical and clinical recurrence. An index mRS ≥ i2b is associated with surgical recurrence, an index mRS ≥ i1 is associated with clinical recurrence, and i1 or i2b with progression to severe endoscopic recurrence. These results support tight monitoring of disease activity and treatment optimization in patients with ileal lesions and a more conservative management in patients with anastomotic lesions.

Re-intervention rates and symptom-free survival at 1year after endoscopic versus surgical management of strictures in Crohn's disease: A propensity matched analysis of a prospective inflammatory bowel disease cohort.

Resection for Crohn's disease (CD) related strictures is definitive but carries risk of morbidity, recurrence, and short bowel syndrome. On the contrary, the durability of endotherapy (ET) for CD-related strictures is questionable. Prospective comparative studies are limited. We aimed to prospectively compare the outcomes of ET in CD strictures with a case-matched surgical therapy (ST) cohort. Patients undergoing ET or resection for primary CD strictures (symptomatic, non-traversable, <5cm length, n≤3) between January 2021 and March 2022 in a high-volume tertiary center were compared with regard to recurrent symptoms, escalation of therapy, re-intervention, and re-operation based on propensity matched analysis. Fifty-nine patients [49% ET, 57.6% male, median (years): 34 (15-74)] had ≥12months of follow up. Before propensity matching, cumulative re-intervention rate was significantly higher with ET [34.5% (10/29) vs 3.3% (1/30) ST, P=0.002]. Recurrent symptoms (34.5% vs 26.7%, P=0.42), escalation of medical therapy (27.5% vs 23.3%, P=0.64), and re-operation (7.4% vs 3.1%, P=0.55) were comparable. In propensity matched analysis adjusted for demographics, disease, and stricture characteristics [n=42, 21 each, 62% male, median (years): 32 (15-60)], cumulative probability of re-intervention rates was higher in ET (28.6% vs 4.8%, P=0.042). The cumulative probability of recurrent symptoms (ET: 33.3% vs surgery 33.3%, P=0.93), therapy escalation (ET: 23.8% vs surgery 28.6%, P=0.75), and re-operation (ET: 9.5% vs surgery 4.8%, P=0.57) was similar. ET for CD strictures require higher re-interventions compared with resection although re-operation could be avoided in the majority with comparable symptom free survival at 1year.

Alpha-tocopherylquinone-mediated activation of the Aryl Hydrocarbon Receptor regulates the production of inflammation-inducing cytokines and ameliorates intestinal inflammation

This study investigated the role of Alpha-tocopherylquinone (TQ) in regulating the intestinal immune system and the underlying mechanisms. In the experimental dextran sodium sulfate and T cell-mediated colitis models, TQ significantly reduced the mRNA levels of interleukin (IL)-6, IL-1β, IL-17A, IL-23, and tumor necrosis factor (TNF)-α and the abundance of proinflammatory macrophages, T helper (Th)17 cells, and ILC3s in the colons of wild-type mice. TQ also prevented lipopolysaccharide (LPS)-induced activation of NFκB and signal transducer and activator of transcription (Stat)-3 pathways in the human macrophage U937 cells. Pharmacological inhibition or CRISPR-Cas-9-mediated knockout of Aryl hydrocarbon Receptor (AhR) prevented the anti-inflammatory effects of TQ in the LPS-treated U937 cells. Furthermore, TQ reduced the mRNA levels of the LPS-induced pro-inflammatory cytokines in the WT but not Ahr-/- mice splenocytes. TQ also reduced IL-6R protein levels and IL-6-induced Stat-3 activation in Jurkat cells and in vitro differentiation of Th17 cells from wild-type but not Ahr-/- mice naive T cells. Additionally, TQ prevented the pro-inflammatory effects of LPS on macrophages and stimulation of T cells in human PBMCs and significantly reduced the abundance of tumor necrosis factor-α, IL-1β, and IL-6hi inflammatory macrophages and Th17 cells in surgically resected Crohn's disease (CD) tissue. Our study shows that TQ is a naturally occurring, non-toxic, and effective immune modulator that activates AhR and suppresses the Stat-3-NFκB signaling.

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

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

Bile acid dysmetabolism in inflammatory bowel diseases

Aim: To summarize the state-of-the-art data on the molecular mechanisms of bile acid (BA) synthesis and absorption, their impaired absorption and receptor-dependent signaling, as well as on the effects of the gut microbiota on BA metabolism in inflammatory bowel diseases (IBD).&#x0D; Key messages: BA malabsorption is one of the relevant mechanisms in the development of diarrhea in IBD. It may occur due to various disorders of the ileum, such as terminal ileitis, ileocolitis or ileocecal resection in Crohn's disease and ileoanal reservoir in ulcerative colitis. Molecular mechanisms of BA malabsorption in IBD are related to a defect in the BA uptake by the apical sodium dependent bile acid transporter (ASBT), as well as to a decrease in the expression of pregnane X receptor (PXR) and farnesoid X receptor (FXR), whose activation by glucocorticoids results in an increase in the BA reabsorption in the ileum and a decrease in hologenic diarrhea. The metabolic profile of luminal BA in IBD is characterized by an increased content of conjugated and 3-OH-sulfated BA and reduced levels of secondary BA. The decrease in the relative abundance of the Lachnospiraceae and Oscillospiraceae spp. in IBD patients leads to a decrease in the efficiency of microbial biotransformation of BA. Changes in the BA metabolic profile in IBD affect the gut microbiota, and impaired interaction with the FXR, PXR, G protein-coupled bile acid receptor (GPBAR1), retinoid-related orphan receptors (RORs) and vitamin D receptor (VDR) results in a pro-inflammatory response and increased intestinal permeability, bacterial translocation, and IBD progression. BA metabolism in IBD-associated primary sclerosing cholangitis (PSC-IBD) is characterized by a significant decrease in the luminal BA pool, and the microbiota composition is remarkable for an increase in the relative abundance of Fusobacterium and Ruminococcus spp., and a decrease in Veillonella, Dorea, Blautia, Lachnospira and Roseburia.&#x0D; Conclusion: Disordered synergistic interplay of BA with intestinal microbiota results in disruption of the ligand-receptor interaction and BA metabolic transformation, which contributes to the activation of the immune system, formation of a vicious circle of chronic inflammation and IBD progression. Further studies into mutual influence of the gut microbiota, BA metabolism and receptor signaling may promote the development of new methods for the diagnosis and treatment of IBD.

Open approach for ileocolic resection in Crohn's disease in the era of minimally invasive surgery: indications and perioperative outcomes in a referral center.

Minimally invasive surgery (MIS) is the first-line approach for ileocolic resection in Crohn's disease (CD), and it is safe and feasible, even with severe penetrating CD or redo surgery. While MIS indications are continually broadening, challenging CD cases might still require an open approach. This study aimed to report rate and indications for an upfront open approach in ileocolic resection for CD. Comprehensive perioperative data for all consecutive patients undergoing ileocolic resection for CD between 2014 and 2021 in a high-volume referral center for CD and MIS, were collected retrospectively. Indications for an upfront open approach were reviewed separately by two authors according to the preoperative visit. Among 319 ileocolic resections for CD, 45 (14%) were open and 274 (86%) MIS. Two or more of the below indications were present in 40 patients (89%) in the open group, while only in 6 patients (2%) in the MIS group (p < 0.0001). Indications for upfront open approach were severe penetrating disease (58%), adhesions at previous surgery (47%), history of abdominal sepsis (33%), multifocal and extensive disease (24%), abdominal wall involvement (22%), concomitant open procedures (9%), small bowel dilatation (9%), and anesthesiologic contraindications (4%). MIS was never performed in a patient with abdominal wall involvement, concomitant open procedure, and anesthesiologic contraindication to MIS. This study can help guide patients, physicians, and surgeons. An abdominal wall involvement or the presence of two of the above indications predicts a high surgical complexity and may be considered as a no-go for the MIS approach. These criteria should prompt surgeons to strongly consider an upfront open approach to optimize the perioperative planning and care of these complex patients.

Surgical morbidity is acceptable following a one or two stage mesentery-including surgery for Crohn’s disease and comparable to mesentery-sparing surgery

Background: It has recently been suggested that mesenteric-including (MI) resection for Crohn’s disease (CD) is associated with reduced surgical recurrence. Whilst there is a perception that MI resection is associated with increased surgical morbidity there is a lack of data to support this. The aim of this study was to perform a retrospective comparison of 30-day morbidity following MI resection and conventional mesenteric-sparing (MS) resection for CD.

P075 Characterisation and structural analysis of a new murine model to study postoperative fibrotic recurrence in Crohn’s disease combining ileocecal resection with chronic colitis

Abstract Background The prevention of postoperative fibrotic recurrence in Crohn’s disease is still an unsolved problem in the management of patients undergoing bowel resection due to fibrotic intestinal strictures. Appropriate murine models are needed to examine the effect of surgery associated factors as well as mechanical and microbial alterations after ileocecal resection on the development of postoperative fibrotic recurrence in Crohn’s disease. Methods We developed a murine model combining chronic dextrane sodium sulfate(DSS)-colitis with ileocecal resection. 9 to 11-week-old C57BL/6 wild-type mice were exposed to 1% DSS via the drinking water for one week followed by ileocecal resection using a microsurgical technique. After surgery, mice recovered for one week after which two more cycles of DSS-administration were performed, now using 1.5% DSS. Between the two postoperative DSS-cycles one week of recovery was implemented. Histology was performed on the distal ileum, the anastomotic area, the proximal colon, and the distal colon. Results The inflammation (proximal colon: median score 5 vs. 0; p &amp;lt; 0.001, distal colon: median score 3 vs. 0; p = 0.003) and fibrosis scores (proximal colon: median score 2 vs. 0; p &amp;lt; 0.001, distal colon: median score 2 vs. 0; p = 0.008) were higher in the colon of mice with chronic DSS-colitis compared to mice without colitis. Furthermore, histomorphometric parameters such as the proportionate collagen area (proximal colon: mean area 6.6% vs. 2.6%; p &amp;lt; 0.001, distal colon: mean area 5.4% vs. 3.7%; p = 0.17) and the submucosal thickness (proximal colon: mean 127.4µm vs. 39.7µm; p &amp;lt; 0.001, distal colon: mean 71.5µm vs. 37.2µm; p = 0.049) were significantly higher in mice with chronic colitis. Interestingly, the most profound inflammatory and fibrotic changes were found in the proximal colon compared to the distal colon. No fibrotic changes were found in the small intestine. Conclusion The combination of ileocecal resection and chronic DSS colitis led to inflammatory and fibrotic changes within the colon. Histopathological features of fibrosis were more prominent in the proximal colon as opposed to the known results from the DSS-colitis model, where inflammatory and fibrotic changes of the intestinal wall worsen towards the distal colon. We thus hypothesize that mechanical and microbial changes due to the altered physiology of the lower gastrointestinal tract after ileocecal resection are responsible for these findings. Continuing research on this model might enable the examination of mechanisms of recurring fibrosis after ileocecal resection in Crohn’s disease.

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.