Surgical Management Of Crohn's Disease Research Articles

Obesity, Sarcopenia and Myosteatosis: Impact on Clinical Outcomes in the Operative Management of Crohn's Disease.

Obesity, sarcopenia, and myosteatosis in inflammatory bowel disease may confer negative outcomes, but their prevalence and impact among patients with Crohn's disease (CD) have not been systematically studied. The aim of this study was to assess nutritional status and body composition among patients undergoing resectional surgery for CD and determine impact on operative outcomes. Consecutive patients with CD undergoing resection from 2000 to 2018 were studied. Total, subcutaneous, and visceral fat areas and lean tissue area (LTA) and intramuscular adipose tissue (IMAT) were determined preoperatively by computed tomography at L3 using SliceOmatic (Tomovision, Canada). Univariable and multivariable linear, logistic, and Cox proportional hazards regression were performed. One hundred twenty-four consecutive patients were studied (ileocolonic disease 53%, n = 62, biologic therapy 34.4% n = 43). Mean fat mass was 22.7 kg, with visceral obesity evident in 23.9% (n = 27). Increased fat stores were associated with reduced risk of emergency presentation but increased corticosteroid use (β 9.09, standard error 3.49; P = .011). Mean LBM was 9.9 kg. Sarcopenia and myosteatosis were associated with impaired baseline nutritional markers. Myosteatosis markers IMAT (P = .002) and muscle attenuation (P = .0003) were associated with increased grade of complication. On multivariable analysis, IMAT was independently associated with increased postoperative morbidity (odds ratio [OR], 1.08; 95% confidence interval (CI), 1.01-1.16; P = .037) and comprehensive complications index (P = .029). Measures of adiposity were not associated with overall morbidity; however, increased visceral fat area independently predicted venous thromboembolism (OR, 1.02; 95% CI, 1.00-1.05; P = .028), and TFA was associated with increased wound infection (OR, 1.00; 95% CI, 1.00-1.01; P = .042) on multivariable analysis. Myosteatosis is associated with nutritional impairment and predicts increased overall postoperative morbidity following resection for CD. Despite its association with specific increased postoperative risks, increased adiposity does not increase overall morbidity, reflecting preservation of nutritional status and relatively more quiescent disease phenotype. Impaired muscle mass and function represent an appealing target for patient optimization to improve outcomes in the surgical management of CD.

Crohn Disease

The role of surgery in the management of Crohn disease has undergone a dramatic evolution over the past 50 years. Currently, surgical treatment of Crohn disease is seldom performed in the emergency setting; it is nearly always performed after failed medical therapy. The general indications for surgical treatment are described and include specific attention to complications of the disease, including obstruction, symptomatic fistulas, abscess formation, cancer or dysplasia, and failure to grow. The special considerations of surgical therapy are also described, including pregnancy, the marking of stoma sites, and the choice of incision, which may involve laparoscopy. Surgical management of Crohn disease is evaluated in terms of therapy at specific sites, including esophageal, gastric, and duodenal disease; jejunoileal disease; ileocolic disease; colonic disease; and anal disease. Chemoprophylaxis is also described, as is surveillance and behavioral modification. Tables outline the Vienna Classification System, Crohn Disease Activity Index, Harvey-Bradshaw Index, extraintestinal manifestations, and the medical treatment of Crohn disease. Figures show endoscopic images of Crohn disease, computed tomographic enterography, a capsule endoscopy showing large Crohn structures, surgery rates over time, caput medusa, an example of stenotic ileocolic Crohn disease, an enterocutaneous fistula, Heineke-Mikulicz strictureplasty, Finney strictureplasty, a fibrotic stricture, an example of a large ulcer, pyoderma gangrenosum, a sigmoid colon stricture, toxic megacolon, and vessel loops for drainage of abscesses. This review contains 15 figures, 5 tables, and 76 references.

SURGICAL STRATEGIES IN MULTIDISCIPLINARY MANAGEMENT OF CROHN'S DISEASE

Despite significant advances in medical therapy, particularly biological agents, a significant number of patients still need surgery as an important therapeutic tool in Crohn's disease (CD). The role of a surgeon in the multidisciplinary team in inflammatory bowel disease care is essential. Discussion with gastroenterologists, radiologists and dietitians to proper define the best timing of surgery after optimization and the best surgical strategy that will be used impact in better postoperative outcomes in CD patients. In this review the authors discuss important aspects involved in the surgical strategies of the multidisciplinary management of CD, including preoperative planning and optimization, the definition of the more adequate approach and technique according to the disease location, and adequate prevention of postoperative recurrence. Several aspects including patients’ past and present features are important in making the right decision in the surgical management of CD. Adequate preparation of the nutritional status, correction of anemia, optimization of medical therapy and anatomic mapping of the small bowel and colon with imaging tests are essential for the definition of best timing and type of surgery in abdominal resections in CD patients. This fact demonstrates the specific need for a multidisciplinary team in the management of CD surgical patients. A pesar de los avances significativos en la terapia médica, particularmente de los agentes biológicos, aún un número significativo de pacientes con enfermedad de Crohn (EC) necesitará de la cirugía como una importante estrategia terapéutica. El papel del coloproctólogo en el equipo multidisciplinario de enfermedad inflamatoria intestinal es fundamental. La discusión con gastroenterólogos, radiólogos y nutriólogos para definir el mejor momento de la cirugía post optimización y la mejor estrategia quirúrgica que se utilizará, impactará en mejores resultados postoperatorios en pacientes con EC. En esta revisión, discutimos importantes aspectos relacionados con las estrategias quirúrgicas del manejo multidisciplinario de la EC, incluyendo el manejo preoperatorio y optimización, la definición del enfoque y la técnica más adecuada de acuerdo a la ubicación de la enfermedad y la prevención más apropiada para el manejo de la recurrencia postoperatoria. Otras variables tales como los antecedentes y las características actuales del paciente, son importantes para tomar la decisión correcta en el tratamiento quirúrgico de la EC. La adecuada preparación del estado nutricional, la corrección de la anemia, la optimización de la terapia médica y la evaluación del intestino delgado y del colon a través de estudios de imágenes son esenciales para definir el mejor momento y el tipo de cirugía en las resecciones intestinales en pacientes con EC. Este hecho muestra la necesidad de un equipo multidisciplinario especializado en el manejo de pacientes quirúrgicos con EC.

Surgical Management of Crohn Disease in Children: Guidelines From the Paediatric IBD Porto Group of ESPGHAN.

The incidence of Crohn disease (CD) has been increasing and surgery needs to be contemplated in a substantial number of cases. The relevant advent of biological treatment has changed but not eliminated the need for surgery in many patients. Despite previous publications on the indications for surgery in CD, there was a need for a comprehensive review of existing evidence on the role of elective surgery and options in pediatric patients affected with CD. We present an expert opinion and critical review of the literature to provide evidence-based guidance to manage these patients. Indications, surgical options, risk factors, and medications in pre- and perioperative period are reviewed in the light of available evidence. Risks and benefits of surgical options are addressed. An algorithm is proposed for the management of postsurgery monitoring, timing for follow-up endoscopy, and treatment options.

NASPGHAN Clinical Report on the Evaluation and Treatment of Pediatric Patients With Internal Penetrating Crohn Disease

Natural History of Pediatric Crohn Disease T he natural history of pediatric Crohn disease (CD) remains unpredictable, although some trends are observed that differentiate children from adults. Pediatric CD often presents with more severe disease and more frequent need for immunosuppressive therapy (1). Growth failure, present in 15% to 20% of patients, is a unique characteristic of pediatric CD not seen in adult-onset CD (2). Colonic disease distribution is common in patients younger than 10 years (1). The need for surgical intervention also varies, with 1 study reporting the actuarial risk of having undergone an extensive intestinal resection being 48.6% 5% in a childhood-onset group versus 14.6% 2% in the adult-onset group (P< 0.001) (1). More recently, long-term follow-up of patients enrolled in pediatric registries shows a cumulative surgical rate of 14% to 17% at 5 years and 28% at 10 years (3,4).

Sa1096 Patient or Procedural Factors: What Drives Readmission After Surgery for Crohn's Disease?

Background: Hospital readmission is associated with increased cost and worse patient outcomes. Readmission has emerged as a surrogate metric of quality. Crohn's disease (CD) patients requiring surgical management are at risk for hospital readmission, which may delay additional therapies. The aim of this study was to assess readmission rates at a tertiary IBD referral center and risk factors in post-operative CD patients in order to identify areas to target for improvement. Methods: We performed a cohort study of colorectal surgery patients captured in the National Surgical Outcome Improvement Program (NSQIP) database with the discharge ICD-9 diagnostic code of 555.x (Crohn's disease, CD) between January 2009-January 2012. Variables of interest included pre-operative medications, disease behavior and phenotype, and pre-operative comorbidities. Primary outcomes of interest were 30day post-operative readmission and post-operative complications. Results: There were 114 Crohn's patients admitted for surgical management of CD over the 3-year period with a 30-day readmission rate of 19.2% (n=22). Within this cohort, the 30-day post-operative complication rate (medical and/or surgical) was 19.2% (95% CI 10.9-24.7). Disease behavior (p=0.09) and location (p=0.70) were not significantly associated with readmission rates. Post-operative complications were the primary risk factor for readmission with 45.5% of readmitted patients experiencing post-operative complications compared to 13.0% among patients not requiring readmission (p=0.002). Average length of stay for the index admission was longer in readmitted patients compared to those not readmitted (13.9 ± 2.8 vs 8.0 ± 0.5 days; p=0.0008). Pre-operative steroid, biologic and immunomodulator use, TPN, weight loss, anemia, prior surgical history, disease duration or emergent surgery were not associated with readmission. Conclusions: Readmission after Crohn's disease surgery is primarily driven by the presence of post-operative complications, not CD location or phenotype. Efforts to reduce 30-day readmissions should focus on early recognition and prevention of postoperative complications. Further study is needed to determine the impact of readmission on the timeline for resuming CD therapies to prevent early disease recurrence.

Successful Laparoscopic Treatment of Duodenal Stenosis in Crohnʼs Disease

Introduction: Duodenal Crohn's disease (CD) is relatively rare and has an estimated incidence of 1% to 2% among patients with CD. Duodenal CD requiring surgery has traditionally been managed with an open bypass procedure. However, more recently, a laparoscopic treatment has become an acceptable surgical option. We report a case of severe duodenal stenosis in CD, successfully treated with laparoscopic gastroduodenal anastomosis (Jabouley's pyloroplasty). Case Presentation: A 30-year old man was diagnosed with CD at age 22 and had been treated medically, including the use of ASA and enteral diet. His disease was refractory to medical therapy, resulting in eventual laparoscopic subtotal colectomy at age 27. He subsequently complained postprandial vomiting and poor oral intake. He was admitted because of gastric outlet obstruction and a weight loss. Endoscopy and upper gastrointestinal (GI) tract X-ray showed a severe deformity and circular inflammatory stenosis of the proximal duodenum extending over 3 cm. A laparoscopic gastroduodenal anastomosis was indicated for duodenal stenosis. At laparoscopy, the duodenal wall was found to be thickened. A duodenal maneuver was fully made, while Jabouley-type pyloroplasty (gastroduodenal side by side anastomosis) was also performed by Endo GIA. A postoperative upper GI X-ray showed an improvement in the gastroduodenal passage. His postoperative course was uneventful and he has remained asymptomatic during follow-up period of 6 months. Discussion: Duodenal CD with severe stenosis has been treated by various modalities including endoscopic dilation, surgical bypass and strictureplasty. However, surgical interventions have been widely adopted because an endoscopic dilation has a high recurrence rate. More recently, a laparoscopic treatment has become an acceptable surgical option in the surgical management of CD. Laparoscopic intervention should be considered in surgical options, since CD is an unremitting condition in which operations are frequently multiple. Conclusion: Laparoscopic gastroduodenal anastomosis for duodenal CD is a useful and safe procedure.

Treatment of Crohn's Disease of Inflammatory, Stenotic, and Fistulizing Phenotypes.

The heterogeneous nature of Crohn's disease (CD) is reflected in the diversity of treatment options available for individual patients. The stratification of CD patients into more homogeneous groups based on disease location and disease behavior may provide clinicians with a more focused approach to therapeutic decision-making. Uncomplicated disease behaviors are typically treated medically. When complications arise and patterns of disease become more aggressive, combined medical and surgical approaches are often necessary and yield favorable results. The surgical management of CD can be as complex as the disease itself, and should involve a surgeon who professes a special expertise in inflammatory bowel disease. Progress in our understanding of the role of the interaction between the environment and the immune system in disease development has led to major advancements in the area of CD therapeutics. Current therapies target the various elements of the inflammatory cascade implicated in the pathogenesis of CD. The anti-inflammatory properties of the pharmacologic therapies presented in this review vary from actions that are extremely broad to those that are cellular or cytokine specific. Maximizing the efficacy of CD-directed therapies while minimizing their toxicity remains the principal objective in developing management strategies for CD patients. Maintaining good quality of life and maximizing adherence to therapies are also important considerations. Despite the various therapeutic options available for CD patients, chosen therapies should be based on the overall treatment goal for individual patients. Therapeutics can be broadly categorized as induction therapies (goal to treat active disease) and maintenance therapies (goal to prevent relapse of disease).

Surgical treatment of inflammatory bowel disease

Appropriate surgical management of Crohn disease is predicated on multiple variables, but stricturoplasty is generally reserved for small bowel disease, whereas resection is utilized in ileocolonic inflammation and favored for large bowel disease. Laparoscopic resection is becoming increasingly useful and justified for ileocolic resections, and segmental resection should be strongly considered for limited large bowel inflammation. Some centers are also using a laparoscopic approach for the surgical treatment of acute or chronic ulcerative colitis, although the benefits are less apparent. Proctocolectomy with ileostomy or ileal pouch-anal anastomosis returns the patient's quality of life to a level comparable to that enjoyed by the general population. Creation of a pouch is performed in most instances, but early complications may warrant pouch revision and later complications, such as pouchitis, can mandate pouch excision.

Surgery of the small bowel.

This review deals with various developments in the field of small-bowel surgery, including the role of ileal pouch-anal anastomosis and ileorectal anastomosis in the treatment of ulcerative colitis and familial adenomatous polyposis. We discuss modern trends in the surgical management of Crohn disease, and the increasing use of laparoscopy in the management of inflammatory bowel disease and small-bowel obstruction. In addition to looking at small-bowel tumors, this review deals with the current status of small-bowel transplantation.