Surgical Treatment Of Crohn's Disease Research Articles

P541 Long-term follow-up results of darvadstrocel for complex perianal fistulas in patients with Crohn's disease: 3-year outcomes from a Japanese phase 3 study

Abstract Background Darvadstrocel (DVS), a suspension of expanded human allogeneic mesenchymal stem cells extracted from adipose tissue, is for the treatment of complex perianal fistulas in patients with Crohn's disease (CD). In Japan, DVS was approved in 2021 based on the Japanese phase 3 study Week 52 data combined with the pivotal study ADMIRE-CD data. Patients who participated in the Japanese study were monitored for 3 years, and we report the results at Week (W) 156. Methods This was an open-label, uncontrolled, phase 3 study (converted to a post-marketing clinical study after approval) conducted from March 2019 to February 2023 in Japan. Subjects had complex Crohn’s perianal fistulas (CPF) refractory to conventional treatments with a maximum of 2 internal openings (IO) and 3 external openings (EO). The fistula tract was curetted approximately 2-3 weeks before DVS administration, and a drainage seton was placed. On the day of administration, seton was removed, fistula tracts were curetted again, and IO was sutured. A total of 24 mL of DVS (including 120x106 cells) was administered around the IO and into the wall of fistula tracts. During the 2-year follow-up period after W52, medical and surgical treatment for CD and CPF was given as needed, and subjects were assessed every 6 months. Results 22 Japanese patients were enrolled from 9 sites. The mean (SD) age was 36.4 (10.4) years, 63.6% were male, and the mean (SD) duration of CD was 11.3 (6.6) years. By W156, most frequently reported adverse events (AE) were anal fistula (7/22), proctalgia (7/22), and nasopharyngitis (6/22). New serious AE occurred after W52 were found in 9 subjects: COVID-19 (4), CD (2), perianal fistula, small bowel obstruction, premature labour (1 each). None of these were considered DVS-related. At W156, the combined remission rate (clinical and MRI assessment) was 15/22 (68.2%, 95% CI [48.7%, 87.6%]), clinical remission rate (clinical assessment) was 15/22 (68.2%, 95% CI [48.7%, 87.6%]), response rate (no drainage from ≥50% of treated EOs) was 20/22 (90.9%, 95% CI [78.9%, 100.0%]), and relapse rate (at least 1 relapse by W156 after achieving remission at W52) was 3/15 (20.0%, 95% CI [0.0%, 40.2%]). Mean Perianal Disease Activity Index (PDAI) total score (SD) was 4.8 (2.2) at baseline, which was decreased to 2.1 (2.1) at W52, and 1.7 (2.0) at W156. Mean Crohn's Disease Activity Index (CDAI) total score (SD) was 94.3 (60.1) on the day of administration, which was decreased to 73.7 (73.6) at W52, and 71.4 (51.2) at W156. Conclusion This is the first prospectively observed clinical outcomes in CPF for 3 years after DVS administration. There were no new safety findings, and fistula remission observed at W52 was maintained until W156.

Short and medium term results of the surgical management of ileocecal Crohn's disease

The treatment of Crohn's disease (CD) is based on medical therapy and surgery is reserved for failure of medical management or complications. To evaluate endoscopic, clinical, and surgical recurrence of CD after surgery. In a prospectively maintained database, consecutive patients older than 15 years subjected to an ileocecal resection for ileocolic disease from January 2011 to April 2021, were identified. The diagnosis of CD was confirmed with the pathologic report. Patients with less than one year of follow-up were excluded. Information was obtained retrospectively from the database and clinical records. Fourteen patients were identified. The mean age at the time of surgery was 38 years. Surgery was performed at a median of 41.5 months (0-300) after the diagnosis of CD, nine elective and five emergency procedures. In five patients there were four major and two minor postoperative complications, with no anastomotic leakage. Six patients had endoscopic recurrence and seven had clinical recurrence (50%) at a mean of 15 months, one of whom required a second operation. There was no mortality. After the surgical treatment of CD, the clinical and endoscopic recurrence rate continues to be high.

Трудности дифференциальной диагностики воспалительных заболеваний кишечника

The clinical case of a complicated course of Crohn's disease (CD) in an elderly patient is presented. The article reflects thefeatures of the diagnosis, tactics of conservative and surgical treatment of CD. Timely diagnosis of colorectal cancer (CRC) in an elderly patient with CD also demonstrated.

Isoperistaltic side-to-side anastomosis for the surgical treatment of Crohn disease.

PurposeIncreasing evidence has shown an association of surgical technique, particularly anastomotic configuration, with postoperative recurrence of CD. This pilot study aimed to evaluate short-term outcomes of isoperistaltic side-to-side anastomosis (ISSA) employed on Crohn disease (CD) patients.MethodsData were retrieved from a prospectively maintained database. Postoperatively, all patients were followed up with close endoscopic (ileocolonoscopy) surveillance.ResultsFrom January 2017 to May 2021, 30 patients diagnosed with CD who underwent ISSA were compared with 45 CD patients who underwent antiperistaltic side-to-side anastomosis (ASSA). The 2 groups were comparable in baseline demographics and clinical characteristics. No significant differences were observed between groups regarding postoperative safety issues, including anastomotic leak, abdominal/pelvic abscess, length of hospital stay, readmission rate within 30 days, etc. At postoperative 24th month, reduced endoscopic recurrence was observed in the ISSA group compared with that in the ASSA group (18 of 24, 75.0%, vs. 36 of 38, 94.7%; P = 0.024). Regarding surgical recurrence, there was 0% in the ISSA group vs. 4.4% (2 of 45) in the ASSA group (P = 0.510).ConclusionIn this study, we aimed to explore the influence of ISSA on postoperative recurrence in CD patients, and the preliminary results show that ISSA was technically safe and feasible, and appears to be effective in reducing postoperative recurrence in CD patients. However, our conclusion was underpowered due to small sample size and inadequate follow-up. We proposed ISSA be considered as another alternative option in the toolbox of inflammatory bowel disease surgeons when performing anastomosis on CD patients.

БОЛЕЗНЬ КРОНА У ДЕТЕЙ: СОВРЕМЕННОЕ СОСТОЯНИЕ ПРОБЛЕМЫ

Crohn's disease (CD) is chronic recurrent bowel disease of unknown etiology, characterized by segmental transmural granulomatous inflammation, mainly with the development of local and systemic complications. Despite the active development of conservative therapy methods, the number of drug-resistant forms of CD and complications of the disease requiring surgical treatment continues to increase. The article reflects modern scientific ideas about the methods of diagnosis, conservative and surgical treatment of CD in children.

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 treatment of complex small bowel Crohn disease.

The clinical presentations of Crohn disease of the small bowel vary from low to high complexity. Understanding the complexity of Crohn disease of the small bowel is important for the surgeon and the gastroenterologist caring for the patient and may be relevant for clinical research as a way to compare outcomes. Here, we present a categorization of complex small bowel Crohn disease and review its surgical treatment as a potential initial step toward the establishment of a definition of complex disease. The complexity of small bowel Crohn disease can be sorted into several categories: technical challenges, namely, fistulae, abscesses, bowel or ureteral obstruction, hemorrhage, cancer and thickened mesentery; extensive disease; the presence of short gut; a history of prolonged use of medications, particularly steroids, immunomodulators, and biological agents; and a high risk of recurrence. Although the principles of modern surgical treatment of Crohn disease have evolved to bowel conservation such as strictureplasty techniques and limited resection margins, such practices by themselves are often not sufficient for the management of complex small bowel Crohn disease. This manuscript reviews each category of complex small bowel Crohn disease, with special emphasis on appropriate surgical strategy.

Difference in Recurrence Patterns Between Anastomosis and Strictureplasty After Surgical Treatment for Crohn Disease

This study aimed to investigate whether the initial indication for surgery or type of surgery (strictureplasty or resection) performed determines recurrence patterns in patients with Crohn disease. Recurrence patterns of 41 patients (31 patients: only resection and anastomosis of the intestine, and 10 patients: strictureplasty with/without resection and anastomosis) who underwent operation for recurrent Crohn disease (June 2002-December 2010) were evaluated. Strictureplasty for nonperforating disease was performed at 17 sites, and reoperation was required at 11 sites (10 sites for nonperforating disease and 1 site for perforating disease). There was a significant difference in the recurrence pattern in patients who underwent resection and anastomosis (P < 0.01) and in patients who underwent strictureplasty with resection and anastomosis (P < 0.05) between sites at which resection and anastomosis was performed for nonperforating and for perforating disease. Initial indication for surgery, but not the type of surgery, appeared to determine recurrence patterns.

Clinical characteristics and surgical treatment of Crohn disease complicated with intra-abdominal abscess

To elucidate the clinical characteristics and surgical treatment of intra-abdominal abscess in patients with Crohn disease(CD). Clinical data of 39 patients with CD complicated with intra-abdominal abscess from 2000 to 2005 were analyzed retrospectively. The cumulative incidence of intra-abdominal abscesses was 27.5%. Of the 39 CD patients with abscess, 61.5% had surgery the time of present study. The mean age of the patients with abscesses was (34.7+/- 12.3) years, and the duration of illness from the onset of CD until development of an abscess was (0-22) years,with 5 years of the average duration. In terms of location of abscess, it occurred most often on the right side (76.9%), especially near the site of anastomosis (48.7%). Most patients (34 cases, 94.4%) were treated with surgical drainage and intestinal resection. Abscess formation was noted in 27.5% of patients with CD, with nearly half of abscesses occurring near the anastomotic site. The mean age of patients with abscess was 35 years, with 5 years of the duration of illness. Most abscesses were treated with operative drainage and intestinal resection.

Epidemiology and surgical treatment of Crohn disease

克罗恩病(Crohn disease,CD)是一种不明原因的、可累及全消化道的慢性复发性肉芽肿性炎症.其在我国乃至全世界范围内的发病率尚不甚清晰,在外科治疗的许多问题上也没有达成共识。

Surgery therapy of Crohn disease complicated with fistula

To investigate the surgical treatment of Crohn disease(CD) complicated with perforation or fistula. The clinical data of 24 CD cases complicated with perforation or fistula treated in our department from Jan. 1980 to Apr. 2005 were analyzed retrospectively. There were 24 cases of CD complicated with perforation or fistula among 181 CD patients,and the incidence of perforation or fistula was 13.3%. Steroid treatment before perforation was given in 8 patients, while not in 9 patients and unclear in 7 patients. Eighteen patients had single perforation, 4 patients two free perforations and 2 patients more than three extra-abdominal fistula. Emergency operation was performed in 8 cases and selective operation in 16 cases. Five cases had postoperative complications including incision infection in 2, intra-abdominal abscess in 2 and stomal fistula in one case, and were all cured by surgical drainage and anti-infection treatment. The morbidity rate was 20.8%. The postoperative mortality rate was 12.5% (3/24). Eighteen patients were followed up from 6 months to 18 years, and the 5-year recurrent rate was 16.7%. The 10-year reoperation rate was 33.3%. Steroid use is not the main cause of perforation or fistula in CD. Perforation or fistula is the definite indication for surgical treatment.

Current Therapy of Inflammatory Bowel Disease in Children

Ulcerative colitis (UC) and Crohn disease (CD) are chronic intestinal inflammatory diseases that can present as bloody diarrhea, abdominal pain, and malnutrition. Collectively, these disorders are referred to as inflammatory bowel disease (IBD). All patients with IBD share a common pathophysiology. However, there are a number of developmental, psychosocial, and physiologic issues that are unique to the approximate, equals 20% of patients that present during childhood or adolescence. These include the possibility of disease-induced delays in linear growth or physical development, differences in drug dosing, and the changes in social and cognitive development that occur as children move from school-age years into adolescence and early adulthood. Gastroenterologists caring for these children must therefore develop an optimal regimen of pharmacologic therapies, nutritional management, psychologic support, and properly timed surgery (when necessary) that will maintain disease remission, minimize disease and drug-induced adverse effects, and optimize growth and development. This article reviews current approaches to the management of patients with UC and CD and highlights issues specific to the treatment of children with IBD. The principal medical therapies used to induce disease remission in patients with UC are aminosalicylates (for mild disease), corticosteroids (for moderate disease), and cyclosporine (ciclosporin) (for severe disease). If a patient responds to the induction regimen, maintenance therapies that are used to prevent disease relapse include aminosalicylates, mercaptopurine, and azathioprine. Colectomy with creation of an ileal pouch anal anastomosis (J pouch) has become the standard of care for patients with severe or refractory colitis and results in an improved quality of life in most patients. Therefore, the risks associated with using increasingly potent immunosuppressant agents must be balanced in each case against a patient's desire to retain their colon and avoid a temporary or potentially permanent ileostomy. Decisions about drug therapy in the management of patients with CD are more complex and depend on both the location (e.g. gastroduodenal vs small intestinal vs colonic), as well as the behavior of the disease (inflammatory/mucosal vs stricturing vs perforating) in a given patient. Induction therapies for CD typically include aminosalicylates and antibiotics (for mild mucosal disease), nutritional therapy (including elemental or polymeric formulas), corticosteroids (for moderate disease), and infliximab (for corticosteroid-resistant or fistulizing disease). Aminosalicylates, mercaptopurine, azathioprine, methotrexate, and infliximab can be used as maintenance therapies. Because surgical treatment of CD is not curative, it is typically reserved for those patients either with persistent symptoms and disease limited to a small section of the intestine (e.g. the terminal ileum and cecum) or for the management of complications of the disease including stricture or abdominal abscess. When surgery is necessary, maintenance medications administered postoperatively will postpone recurrence. Patients with UC and CD are at risk for the development of micronutrient deficiencies (including folate, iron, and vitamin D deficiencies) and require close nutritional monitoring. In addition, patients with UC and CD involving the colon are at increased risk of developing colon cancer, and should be enrolled into a colonoscopy surveillance program after 8-10 years of disease duration.

Giant Inflammatory Polyposis Coli as a Manifestation of Crohn's Disease in Patients with Coexistent Cystic Fibrosis

Crohn's disease (CD) arising in children with cystic fibrosis (CF) is well recognized. Indeed, reports suggest that CD is significantly more common in patients with CF than in the general population. Giant inflammatory polyposis is a rare manifestation of idiopathic inflammatory bowel disease and may complicate both ulcerative colitis and CD. Giant inflammatory polyposis has not been specifically reported in patients with coexistent CF and CD. Herein, we report the occurrence of giant inflammatory polyposis in 2 boys attending a tertiary care hospital, with an established diagnosis of CF who subsequently developed CD. Both boys required surgical treatment for CD. In addition to classical features of CD, both colonic resection specimens showed giant inflammatory polyposis. The appearances were modified by the presence of a layer of thick mucus. It is suggested that the coexistence of CF in patients with CD may predispose to the development of giant inflammatory polyposis. In addition to contributing to their development, it also appears that there is a propensity for CF to alter the morphological appearance of giant inflammatory polyposis. This may lead to diagnostic confusion when examining endoscopic biopsies.

Worse clinical course of disease in Crohn??s patients with previous appendectomy

The aim of the present study was to assess the effect of previous appendectomy in a series of Crohn's disease (CD) patients on the clinical characteristics and course of disease. Demographic and clinical data were retrospectively analysed for 129 consecutive outpatients (68 men and 61 women, median age 38 years) with CD. For each patient, information concerning appendectomy, indication for surgery (acute/chronic) and the date of surgery were recorded. The date of the appendectomy in relation to the date of CD diagnosis was carefully assessed in order to evaluate the precise relationship between the two events. A total of 129 CD patients who had not undergone previous appendectomy served as controls. The severity of disease was assessed retrospectively by evaluating the need for systemic steroids, immunosuppressants and surgical treatment for CD, particularly resective procedures. Forty-one CD patients (31.8%) underwent appendectomy before the diagnosis of disease. Appendectomy before diagnosis showed a negative association with colonic disease localization and with articular manifestations. In addition, the 41 patients with previous appendectomy had a significantly greater risk of surgery, particularly resective. Multivariate analysis confirmed appendectomy performed before diagnosis as an independent risk factor for surgery; on the contrary, colonic site and inflammatory type of disease were independent factors protecting against surgery. Although current smokers were at an increased risk of surgical treatment, a smoking habit alone did not seem to be relevant at the multivariate analysis. The results of this study indicate a worse clinical course of CD in patients appendicectomized before diagnosis.

Patients with Crohn's disease are unaware of the risks that smoking has on their disease.

Smoking, both in quantity and duration, increases the risk of recurrent Crohn's disease (CD) and the need for surgical treatment of CD. This study assessed awareness among patients with CD of the risks of smoking on their disease. We distributed self-administered questionnaires to 714 CD patients under follow-up at the University Hospital Birmingham, United Kingdom. We asked the patients eight multiple-choice (yes/uncertain/no) questions about the effects of smoking on health and on CD. We also determined relevant patient demographics, smoking history, and medical history. A total of 312 patients completed the questionnaire. Patients acknowledged the dangers of smoking on overall health (91.5%), lung cancer (89.6%), lung disease (90.8%), and cardiovascular disease (85.3%). Employed, educated, and homeowning patients demonstrated significantly more recognition of these smoking risks. Conversely, few patients recognized that smoking increases the risks of development of CD (9.5%) and of reoperation for CD (12.0%). Moreover, few patients recognized that both the quantity of cigarettes smoked (11.4%) and the duration of smoking (17.4%) increase the risk of reoperation. Patients with CD are unaware of the risks that smoking has on their disease, indicating a need for increased patient education with regard to the effects of smoking on CD.

The impact of surgery on health related quality of life in Crohn's disease

When patients with Crohn's disease (CD) express concerns about their disease, they emphasize worries about surgery. However, postsurgical changes in health related quality of life (HRQOL) in patients with CD have been barely studied, and published results are somewhat discrepant. In the present study we assessed whether surgical treatment of refractary or complicated CD modifies HRQOL. Outcomes of 27 patients with previous intestinal or colonic resection were compared to 39 non-operated patients and to a reference control group of 63 healthy individuals. All patients were in clinical remission at the time of study. Age and sex were similar in the three groups. Mean CD recurrence/year index was similar for operated and nonoperated patients, but the interval from diagnosis to interview was longer in operated patients (median [95% CI]: 100 [81-160] months vs 48 [46-78], p<0.01). HRQOL was assessed by a validated spanish version of the Inflammatory Bowel Disease Questionnaire (IBDQ), that included five dimensions: intestinal symptoms, general symptoms, emotional, social and functional. A general HRQOL questionnaire (Psychological General Well Being Index -PGWBI-) and a visual analogue scale (VAS) of HRQOL were also administered to CD patients. RESULTS: Analysis of variance showed that both operated and non-operated CD patients scored lower, indicating a poorer HRQOL, than controls in global IBDQ and all five dimensions. However, neither global score, digestive and systemic symptoms, emotional and functional dimensions differed significantly between operated and nonoperated CD patients. PGWBI and VAS were also similar in both groups of CD patients (101 [93-106] vs 104 [97-107] and 85 [71-85] vs 80 [75-84] respectively). Only the social dimension of IBDQ was scored lower by operated vs non-operated CD patients (6.2 [4.8-6.8] vs 6.5 [4.3-7.0], p=0.01). In conclusion, although CD impairs the HRQOL, as compared to healthy controls, surgical treatment of CD patients does not worsen their HRQOL except in social dimension.

Surgical treatment of Crohn disease in children and adolescents; how conservative can the paediatrician be?

Thirty-eight children (21 male, 17 female, age 3-18 years), treated for Crohn disease in two Dutch university centres, were retrospectively studied in order to evaluate the results of conservative treatment and to find out in what way surgical treatment in this age group may have differed from treating adults with this disease. Both groups had an equal distribution of age and sex. Diarrhoea with discharge of blood and mucus, abdominal pain, nausea/vomiting, weight loss, fever and general discomfort were the most frequent presenting symptoms. Twenty-three children (60%) showed signs of malabsorption; 4 children (10%) had growth retardation. In 27 children (70%), 63 surgical procedures were performed (2.4 operations per child). There was no surgical mortality. Most operations were performed for ileocolitis and colon-only localizations needed most re-operations. Of the surgical procedures performed, 55% were excisional procedures. Already 3 years after the onset of symptoms, 50% of all children had had their first resection, whereas in adults, 50% of the patients undergo surgery 8 years after disease onset. Eight children were treated with split ileostomy. In only one of these children, operated for non-toxic colitis and severe steroid-dependent growth retardation, could the colon eventually be saved. The time between the onset of symptoms and the first operation seems to be shorter in children compared to adults. Severe malabsorption and growth retardation are additional specific indications for surgery for Crohn disease in childhood. The latter combined with non-toxic colitis, may perhaps be the only indication left for performing split ileostomy in Crohn disease.