Ileocolic resection with temporary ileostomy for Crohn's disease: does it affect long-term disease recurrence compared with primary anastomosis?

Goldenshluger M ，Segev L 《-》

Postoperative Crohn's Disease Recurrence Risk and Optimal Biologic Timing After Temporary Diversion Following Ileocolic Resection.

Postoperative recurrence of Crohn's disease (CD) is common. While most patients undergo resection with undiverted anastomosis (UA), some individuals also have creation of an intended temporary diversion (ITD) with an ileostomy followed by ostomy takedown (OT) due to increased risk of anastomotic complications. We assessed the association of diversion with subsequent CD recurrence risk and the influence of biologic prophylaxis timing to prevent recurrence in this population. This was a retrospective cohort study of CD patients who underwent ileocolic resection between 2009 and 2020 at a large quaternary health system. Patients were grouped by continuity status after index resection (primary anastomosis or ITD). The outcomes of the study were radiographic, endoscopic, and surgical recurrence as well as composite recurrence postoperatively (after OT in the ITD group). Propensity score-weighted matching was performed based on risk factors for diversion and recurrence. Multivariable regression and a Cox proportional hazards model adjusting for recurrence risk factors were used to assess association with outcomes. Subgroup analysis in the ITD group was performed to assess the impact of biologic timing relative to OT (no biologic, biologic before OT, after OT) on composite recurrence. A total of 793 CD patients were included (mean age 38 years, body mass index 23.7 kg/m2, 52% female, 23% active smoker, 50% penetrating disease). Primary anastomosis was performed in 67.5% (n = 535) and ITD in 32.5% (n = 258; 79% loop, 21% end) of patients. Diverted patients were more likely to have been males and to have had penetrating and perianal disease, prior biologic use, lower body mass index, and lower preoperative hemoglobin and albumin (all P < .01). After a median follow-up of 44 months, postoperative recurrence was identified in 83.3% patients (radiographic 40.4%, endoscopic 39.5%, surgical 13.3%). After propensity score matching and adjusting for recurrence risk factors, no significant differences were seen between continuity groups in radiographic (adjusted hazard ratio [aHR], 1.32; 95% confidence interval [CI], 0.91-1.91) or endoscopic recurrence (aHR, 1.196; 95% CI, 0.84-1.73), but an increased risk of surgical recurrence was noted in the ITD group (aHR, 1.61; 95% CI, 1.02-2.54). Most (56.1%) ITD patients started biologic prophylaxis after OT, 11.4% before OT, and 32.4% had no postoperative biologic prophylaxis. Biologic prophylaxis in ITD was associated with younger age (P < .001), perianal disease (P = .04), and prior biologic use (P < .001) but not in recurrence (P = .12). Despite higher rates of objective disease activity identified before OT, biologic exposure before OT was not associated with a significant reduction in composite post-OT recurrence compared with starting a biologic after OT (52% vs 70.7%; P = 0.09). Diversion of an ileocolic resection is not consistently associated with a risk of postoperative recurrence and should be performed when clinically appropriate. Patients requiring diversion at time of ileocolic resection are at high risk for recurrence, and biologic initiation prior to stoma reversal may be considered.

Joseph A ，Bachour SP ，Shah R ，El Halabi J ，Syed H ，Lyu R ，Cohen B ，Rieder F ，Achkar JP ，Philpott J ，Qazi T ，Hull T ，Lipman J ，Wexner S ，Holubar SD ，Regueiro M ，Click B ... -  《-》

KONO-S Anastomosis Is Not Superior to Conventional Anastomosis for the Reduction of Postoperative Endoscopic Recurrence in Crohn's Disease.

Tyrode G ，Lakkis Z ，Vernerey D ，Falcoz A ，Clairet V ，Alibert L ，Koch S ，Vuitton L ... -  《-》

Morbid obesity among Crohn's disease patients is on the rise and is associated with a higher rate of surgical complications after ileocolic resection.

Crohn's disease (CD) is regarded as a wasting disease, yet there is a growing population of CD patients with a body mass index (BMI) of 35 and above. The rate of postoperative complications is relatively high in CD patients but might be even higher in CD with morbid obesity (MO). This was a retrospective study using a prospectively maintained database of all patients undergoing Ileocolic resection for CD between 2014 and 2021 in two referral centres, comparing postoperative complication rates according to BMI. Three hundred and forty-six patients were identified. Sixty patients (17%) had a BMI over 30 kg/m2, and 28 (8.1%) had a BMI of over 35 kg/m2 (>35 group). The BMI >35 group had more women (78.6% vs. 52%, P < 0.1), a higher rate of patients not receiving an anastomosis (7.1% vs. 2.5%, P = 0.02), a higher rate of any postoperative surgical complication (32.1% vs. 25.2%, P = 0.4), with a higher rate of Clavien-Dindo ≥3 (14.3% vs. 7.2%, P = 0.25), a higher rate of stoma creation on reoperation for complications (7.2% vs. 1.7%, P = 0.04), a higher rate of 30-day readmission due to intra-abdominal abscess (10.7% vs. 4.7%, P = 0.2), but a lower rate of postoperative medical complications (3.6% vs. 15.7%, P < 0.01). The rate of MO among CD patients requiring ileocolonic resection is on the rise. MO in this setting is associated with statistically non-significant increases in all surgical complications, severe complications, readmission, and a higher chance for a bailout stoma creation upon reoperation. However, MO seems to be a protective factor for medical postoperative complications, which might suggest better nutritional status.

Rudnicki Y ，Calini G ，Abdalla S ，Colibaseanu D ，Larson DW ，Mathis KL ... -  《-》

Durable remission after ileocolic resection for Crohn's disease is achievable in selected patients. Long-term results of a prospective multicentric cohort study of the GETAID Chirurgie.

Postoperative recurrence requiring medical treatment intensification or redo surgery is common after ileocolic resection (ICR) for Crohn's disease (CD). This study aimed to identify a subgroup of CD patients for whom ICR could achieve durable remission. This retrospective follow-up study analyzed 592 CD patients who underwent ICR (2013-2015) in a nationwide prospective cohort. Patients with >36 months follow-up were included. Primary outcome was durable remission, defined as the absence of endoscopic recurrence and/or medical treatment intensification. Uni- and multivariate analyses identified predictive factors for durable remission. Among 268 included patients, 59% had B2 phenotype, 70% had a first ICR, and 66% had postoperative medical treatment. After a median follow-up of 85 (36-104) months, 52 patients (19%) experienced durable remission, of whom 24 (46%) didn't require medical treatment and 28 (54%) maintained the same postoperative treatment, including anti-tumor necrosis factor in 15/28 patients (54%). Surgery could stabilize the disease course in 112 patients (41.7%), including 22.4% endoscopic recurrence that didn't require CD treatment initiation or intensification. Durable remission rate was significantly increased in B1 phenotype vs B2/B3 (n = 7/18;39% vs n = 45/250;18%, P = .030) and in first ICR vs redo ICR (n = 43/184;23% vs n = 9/80;11%, P = .023). In multivariate analysis, B1 phenotype was the only independent predictive factor for durable remission (odds ratio = 3.59, IC 95%, 1.13-11.37, P = .030). Surgery for CD achieved durable remission in 20%, rising to 40% in those with a B1 phenotype. These results support surgery as a viable alternative to medical treatment, offering treatment-free durable remission and preserving medical treatment options.

Abdalla S ，Benoist S ，Maggiori L ，Lefèvre JH ，Denost Q ，Cotte E ，Germain A ，Beyer-Berjot L ，Desfourneaux V ，Rahili A ，Duffas JP ，Pautrat K ，Denet C ，Bridoux V ，Meurette G ，Faucheron JL ，Loriau J ，Souche FR ，Corte H ，Vicaut É ，Zerbib P ，Panis Y ，Brouquet A ... -  《-》