scholarly journals The Predictive Value of Inflammation at Ileocecal Resection Margins for Postoperative Crohn’s Recurrence: A Cohort Study

2019 ◽  
Vol 26 (11) ◽  
pp. 1691-1699 ◽  
Author(s):  
Karin A T G M Wasmann ◽  
Jojanneke van Amesfoort ◽  
Maurits L van Montfoort ◽  
Lianne Koens ◽  
Willem A Bemelman ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Medical Treatment ◽  
Predictive Value ◽  
Resection Margin ◽  
Postoperative Recurrence ◽  
Colonic Resection ◽  
Ileocecal Resection ◽  
Resection Margins ◽  
Distal Resection Margin ◽  
Active Inflammation

Abstract Background Resections for Crohn’s disease should be limited and only resect macroscopically affected bowel. However, recent studies suggest microscopic inflammation at resection margins as a predictor for postoperative recurrence. The clinical impact remains unclear, as non-uniform pathological criteria have been used. The aim of this study was to assess the predictive value of pathological characteristics at ileocecal resection margins for recurrence. Methods Both resection margins of 106 consecutive patients undergoing ileocecal resection for Crohn’s disease between 2002 and 2009 were revised and scored for active inflammation, myenteric plexitis, and granulomas. Pathological findings were correlated to recurrence, defined as recurrent disease activity demonstrated by endoscopy (modified Rutgeerts score ≥i2) requiring upscaling medical treatment, using multivariate analysis. Results Active inflammation was found at the proximal and distal resection margin in 27% and 15% of patients, respectively, myenteric plexitis in 37% and 32%, respectively, and granulomas in 4% and 6%, respectively. In total, 47 out of 106 patients developed recurrence. Only active inflammation at the distal colonic resection margin was an independent significant predictor for recurrence (88% vs 43% vs 51% for distal, proximal, and no involved margins, respectively; P < 0.01). Conclusion Active inflammation at the distal colonic resection margin after ileocecal resection identifies a patient group at high risk for postoperative recurrence both at the anastomotic site and the colon because it identifies undiagnosed L3 disease. These patients have a different and more aggressive natural history and require more intense medical treatment. Therefore, pathological evaluation of the distal resection margin should be implemented in daily practice.

scholarly journals Microscopic inflammation in ileocecal specimen does not correspond to a higher anastomotic leakage rate after ileocecal resection in Crohn’s disease

PLoS ONE ◽  
2021 ◽  
Vol 16 (3) ◽  
pp. e0247796
Author(s):  
Christian Schineis ◽  
Andrea Ullrich ◽  
Kai S. Lehmann ◽  
Christoph Holmer ◽  
Johannes C. Lauscher ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Anastomotic Leakage ◽  
Resection Margin ◽  
Frozen Section ◽  
Leakage Rate ◽  
Ileocecal Resection ◽  
Resection Margins ◽  
Anastomotic Leakage Rate ◽  
Microscopic Inflammation

Background Patients with Crohn’s disease suffer from a higher rate of anastomotic leakages after ileocecal resection than patients without Crohn’s disease. Our hypothesis was that microscopic inflammation at the resection margins of ileocecal resections in Crohn’s disease increases the rate of anastomotic leakages. Patients and methods In a retrospective cohort study, 130 patients with Crohn’s disease that underwent ileocecal resection between 2015 and 2019, were analyzed. Anastomotic leakage was the primary outcome parameter. Inflammation at the resection margin was characterized as “inflammation at proximal resection margin”, “inflammation at distal resection margin” or “inflammation at both ends”. Results 46 patients (35.4%) showed microscopic inflammation at the resection margins. 17 patients (13.1%) developed anastomotic leakage. No difference in the rate of anastomotic leakages was found for proximally affected resection margins (no anastomotic leakage vs. anastomotic leakage: 20.3 vs. 35.3%, p = 0.17), distally affected resection margins (2.7 vs. 5.9%, p = 0.47) or inflammation at both ends (9.7 vs. 11.8%, p = 0.80). No effect on the anastomotic leakage rate was found for preoperative hemoglobin concentration (no anastomotic leakage vs. anastomotic leakage: 12.3 vs. 13.5 g/dl, p = 0.26), perioperative immunosuppressive medication (62.8 vs. 52.9%, p = 0.30), BMI (21.8 vs. 22.4 m2/kg, p = 0.82), emergency operation (21.2 vs. 11.8%, p = 0.29), laparoscopic vs. open procedure (p = 0.58), diverting ileostomy (31.9 vs. 57.1%, p = 0.35) or the level of surgical training (staff surgeon: 80.5 vs. 76.5%, p = 0.45). Conclusion Microscopic inflammation at the resection margins after ileocecal resection in Crohn’s disease is common. Histologically inflamed resection margins do not appear to affect the rate of anastomotic leakages. Our data suggest that there is no need for extensive resections or frozen section to achieve microscopically inflammation-free resection margins.

scholarly journals Predictive value of tissue calprotectin for disease recurrence after ileocecal resection in pediatric Crohn's disease

2021 ◽  
Author(s):  
Kristyna Zarubova ◽  
Ondrej Fabian ◽  
Ondrej Hradsky ◽  
Tereza Lerchova ◽  
Filip Mikus ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Predictive Value ◽  
Disease Recurrence ◽  
Ileocecal Resection

Mucosal Recolonization after Ileocecal Resection Differs in Crohn's Disease Patients Developing Postoperative Recurrence

2017 ◽  
Vol 152 (5) ◽  
pp. S990
Author(s):  
Kathleen Machiels ◽  
Marta Pozuelo del Río ◽  
João Sabino ◽  
Alba Santiago ◽  
David Campos ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Postoperative Recurrence ◽  
Ileocecal Resection

Postoperative Management of Crohn’s Disease: What Can We Do to Prevent Recurrence?

2016 ◽  
Vol 2 (11) ◽  
Author(s):  
Adriana Georgiana Olariu ◽  
Liliana Bordeianou
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Disease Recurrence ◽  
Postoperative Recurrence ◽  
Postoperative Management ◽  
Chronic Inflammatory Bowel Disease ◽  
Ileocecal Resection ◽  
Endoscopic Recurrence ◽  
Relapsing Remitting ◽  
Patients Experience

<p>Crohn’s disease (CD) is a chronic inflammatory bowel disease with a relapsing, remitting course.  Approximately one in four CD patients requires surgery within five years of diagnosis. Unfortunately, surgery is rarely curative and up to 70% of CD patients experience endoscopic recurrence and 40% have clinical disease recurrence within 18 months after surgery.</p><p> </p><p>This review is aimed at providing internists and gastroenterologists a foundation for the management of patients who underwent ileocecal resection for CD. We provide an overview of the current definitions of postoperative recurrence and prognostic factors for postoperative CD recurrence. As recent studies raised concerns about the value of these factors, we examine the evidence behind the current risk stratification algorithm and pharmacologic treatment recommendations. Lastly, we discuss future directions for research.</p>

The Effect of Formalin Fixation on Resection Margins in Colorectal Cancer

2019 ◽  
Vol 27 (7) ◽  
pp. 700-705
Author(s):  
David Lam ◽  
Yui Kaneko ◽  
Adam Scarlett ◽  
Basil D’Souza ◽  
Richard Norris ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Rectal Cancer ◽  
Circumferential Resection Margin ◽  
Resection Margin ◽  
Neoadjuvant Chemoradiotherapy ◽  
Recurrence Risk ◽  
Formalin Fixation ◽  
Resection Margins ◽  
Distal Resection Margin ◽  
Radial Margin

Resection margins in colorectal cancer carry clinical significance with regard to disease recurrence risk and selection for multimodal adjuvant therapy, especially with circumferential resection margins in rectal cancer. Colorectal cancer specimens are routinely fixed in formalin, which results in specimen and tumor-free margin shrinkage. However, the effects of shrinkage have not traditionally been taken into account when analyzing tumor-free margins. In this prospective study, 46 colorectal cancer specimens were measured in the fresh state and subsequently after formalin fixation for total specimen length, distal resection margin, and radial margin (circumferential resection margin for rectal cancer). The mean reduction after formalin fixation was 17.48 mm (14.7%) for distal resection margin and 1.20 mm (10.5%) for radial margin. For rectal cancer, circumferential resection margin reduction was 0.88 mm (11.8%); this was not affected by neoadjuvant chemoradiotherapy. Duration of formalin fixation did not significantly affect the extent of margin shrinkage. This is the first study to evaluate the effect of formalin fixation on radial resection margins, specifically as it relates to rectal cancer, and it demonstrates that shrinkage from formalin fixation should be a consideration in decision-making where the magnitude of tumor-free margins is small.

scholarly journals P617 Mesenchymal stromal cells of bone marrow reduce the risk of postoperative recurrence of Crohn’s disease

2020 ◽  
Vol 14 (Supplement_1) ◽  
pp. S513-S514
Author(s):  
O Knyazev ◽  
A V Kagramanova ◽  
A Lishchinskaya ◽  
A Parfenov
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Stromal Cells ◽  
Postoperative Recurrence ◽  
Low Risk ◽  
Average Level ◽  
Ileocecal Resection ◽  
Terminal Ileitis ◽  
Relapse Therapy

Abstract Background Crohn’s disease (CD) in the form of terminal ileitis occurs in approximately 1/3 of CD patients and is often complicated by the formation of ileum stricture or ileocecal valve. The operation of choice is resection of ileocecal Department with the formation of ileo of ascendants. Depending on the combination of risk factors, as well as on the effectiveness of previous anti-relapse therapy, patients after surgery should be stratified into groups with different risks of postoperative recurrence. The objective of the study was to evaluate the effectiveness of mesenchymal stem/stromal cells (MS/SC) as anti-relapse therapy in patients with low-risk CD after ileocecal resection. Methods Thirty-six patients with CD in the form of terminal ileitis with a stricture of the terminal ileum with signs of intestinal obstruction after the ineffectiveness of the course of conservative therapy (application of GCS) underwent resection of the ileocecal Department with the formation of ileo-ascendoanastomosis. All patients had a low risk of postoperative recurrence of Crohn’s disease. However, the first group of patients aged 19 to 58 years (Me-29) (n = 18) received MS/SC. The second group of patients aged 20 to 68 years (Me-36) (n = 18) received mesalazine 4 gr/day. The follow-up period was 60 months. The monitoring was carried out by endoscopic picture and/or CT-enterography, C-RP level, faecal calprotectin (FCP). Average baseline CRP in the first group was 29.5 ± 3.2 mg/l, in the second – to 27.75 ± 3.0 (p = 0.73), the level of the FCP in the first group 1019.4 ± 97.2 mkg/g, in the second – 998.8±127.3 mkg/g (p = 0,9). Results After 24 months in the first group of patients the average level of C-RP was 9.5 ± 1.9 mg/l, in the second group 17.8 ± 3.3 mg/l (p = 0.027). The level of the FCP in the first group 98.0 ± 12.1 mkg/g, in the second 121.7 ± 14.2 mkg/g (p = 0.27). After 24 months of follow-up, 1 (5.5%) patient from the first group (n = 18) had a relapse that required the appointment of GCS. In the second group, relapse occurred in 4 (22.2%) patients out of 18 (RR 0.25; 95% CI 0.031–2.025; p = 0.15). After 60 months in the first group of patients, the average level of C-RP was 10.76 ± 2.1 mg/l, in the second group 19.2 ± 3.5 mg/l (p = 0.039). The level of the FCP in the first group of 100.4 ± 13.7 per mkg/g, in the second 191.7 ± 24.9 mkg /g (p = 0.002). After 60 months of follow-up, 1 (5.5%) patients from the first group had a relapse. In the second group, relapse occurred in 8 (22.2%) patients out of 18 (RR 0.125; 95% CI 0.017–0.9; p = 0.008). Conclusion The use of mesenchymal stem/stromal cells (MS/SC) as anti-relapse therapy in patients with low-risk CD after ileocecal resection significantly reduces the risk of postoperative recurrence of CD.

scholarly journals 486 Are Surgical Resection Margins A Risk Factor for Crohn’s Disease Recurrence?

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
A A Haiduc ◽  
R Patel ◽  
A Karim
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Disease Activity ◽  
Surgical Resection ◽  
Colonic Resection ◽  
Sufficient Evidence ◽  
Resection Margins ◽  
Related Factors ◽  
Clinical Recurrence ◽  
Disease Free

Abstract Despite advances in treatment, Crohn’s disease (CD) recurrence is still high. Various factors correlated with recurrence are studied however, there is no consensus regarding the importance of disease-free resection margins. Our goal was to ascertain whether surgical margins predict recurrence rates of CD and identify other potential factors correlated with recurrence. This is a retrospective cohort study on patients who have had a colonic resection for CD from December 2016 to November 2019. Demographics, surgical procedure details, disease activity at resection margins and number of readmissions were recorded. Clinical recurrence was defined as readmission to hospital for a Crohn’s related flare-up within 12 months of surgical resection. Positive disease activity at the resection margins was defined histologically. We compared the readmission rate between all categories. Of the 55 patients identified, 52 (22 female) were included. Of these, seven were readmitted, six are smokers, 19 had mesenteric excision and 33 had Crohn’s positive resection margins. Chi-squared tests showed there are no significant correlations between patient and procedure variables, and readmission rates (p &gt; 0.05). We have not found sufficient evidence to conclude that a disease-free resection margin post colonic resection or any other patient-related factors are associated with decreased recurrence of CD.

scholarly journals P571 Optimal biologic management of endoscopic postoperative recurrence following ileocecal resection in Crohn’s disease

2021 ◽  
Vol 15 (Supplement_1) ◽  
pp. S529-S531
Author(s):  
S Bachour ◽  
R Shah ◽  
R Lyu ◽  
F Rieder ◽  
B Cohen ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Biologic Therapy ◽  
Remission Rate ◽  
Management Strategies ◽  
Treatment Strategies ◽  
Postoperative Recurrence ◽  
Ileocecal Resection ◽  
Tertiary Center ◽  
Endoscopic Remission

Abstract Background Endoscopic postoperative recurrence (POR) of Crohn’s Disease (CD) following ileocolonic resection (ICR) is common; however, optimal treatment strategies of identified POR are unknown. We assessed the role of biologic therapy to treat endoscopic POR in a real-world cohort. Methods Retrospective cohort study of adult CD patients who underwent ICR from 2009–2020 at a tertiary center. Patients with endoscopic POR detected on postoperative colonoscopy and a subsequent follow-up colonoscopy were included. Patients were categorized by biologic therapy at time of POR and further sub-grouped by therapy modification after POR detection (no change, therapy optimization, or change in biologic class). Therapy optimization included: starting or modifying immunomodulator therapy, corticosteroids, or budesonide. POR was defined by Rutgeerts’ ≥ i2b. Results 203 CD patients (49.8% female, 15.4% &gt; 1 prior ICR, 49.0% pre-operative biologic exposure) were included. Of these, 137 (67%) patients were not on biologic therapy at POR detection: 43% subsequently started a biologic, 23% optimized therapy, and 34% had no change. 66 (33%) patients were on anti-TNF at POR identification: 24% subsequently changed biologic class, 48% optimized anti-TNF, and 27% had no change (Figure 1). There was no difference in median time from ICR to POR detection (483 days, p=0.08) or inter-colonoscopy interval (483 days, p=0.25) between groups. In patients not on biologics at POR detection, those who started a biologic saw a 21% increase in subsequent endoscopic remission compared to those who optimized therapy (49.2% vs 28.1%, p=0.09) and a 12% increase compared to those who received no change (49.2% vs 37%). In patients not on biologics with severe POR (i3/i4, n=62), there was significantly higher remission rate by starting biologic therapy compared to optimizing existing therapy (53.3% vs 16.7%) or no change (53.3% vs 35.7%), p=0.04. In individuals receiving anti-TNF at time of POR, there was a 25% increase in endoscopic remission in patients who switched biologic class compared to those who optimized therapy (56.2% vs 31.2%) and a 34% increase compared to those with no change (56.2% vs 22.2%), p=0.1. Furthermore, significantly higher rates of improved Rutgeerts’ score were observed in switching biologic class compared to therapy optimization (68.8% vs 43.8%) or no change (68.8% vs 27.8%), p=0.04. Conclusion After endoscopic POR detection following ICR, initiating biologic therapy in individuals not previously receiving it, and changing mechanism of action in those already receiving anti-TNF, may improve clinical outcomes compared to alternative management strategies. If confirmed, these findings may inform optimal management strategies for endoscopic POR.

scholarly journals P171 Does microscopic involvement of the surgical margins after ileocececal resection in Crohn’s disease patients predicts early recurrence?

2020 ◽  
Vol 14 (Supplement_1) ◽  
pp. S223-S223
Author(s):  
M ZEMEL ◽  
E Solo ◽  
J Klausner ◽  
H Tulchinsky
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Medical Treatment ◽  
Disease Recurrence ◽  
Male Gender ◽  
Stapled Anastomosis ◽  
Perianal Disease ◽  
Ileocecal Resection ◽  
Resected Specimen ◽  
Histopathological Evidence

Abstract Background Past research has identified different factors which are associated with post-operative recurrence of Crohn’s disease (CD). However, controversy remained whether the microscopic presence of CD in the margins of the resected specimen increases the risk of recurrence. The main aim of our study was to determine whether microscopic presence of CD in the resected specimen margin in patients who underwent ileocecal resection predicts disease recurrence. The secondary aim was to identify other risk factors for recurrence. Methods We retrospectively evaluated all CD patients who underwent ileocecal resection in our unit between 2000 and 2015. The diagnoses of CD and information regarding the margins’ involvement were retrieved from pathology reports. Recurrence was indicated according to medical records or according to specific phone questionnaire. Demographic and clinical parameters where compared between patients with and without histopathological evidence of CD in the resected margins. Results 202 CD patients were included: 49 patients with histopathological evidence of CD in the resected margins and 153 patients without involvement. The main demographic characteristics were similar. Patients who received preoperative medical treatment had statistically significant higher rate of uninvolved margins (90.8 vs. 77.6%, p = 0.03). Technical aspects including surgical approach, conversion rates to open surgery, and anastomotic methods were similar. Likewise, the post-operative course regarding medical treatment, endoscopic and clinical recurrence, and reoperation rates was also similar. We found a statistically significant shorter time for disease recurrence in laparoscopic surgery (HR 1.6, CI 1.1–2., p = 0.02(, stapled anastomosis (HR 1.7, CI 1.2–2.6, p = 0.01), if stricturoplasty was done in addition to the ileocecal resection (HR 1.7, CI 1.1–2.6, p = 0.02(, and in patients with perianal disease (HR 1.7, CI 1.1–2.6, p = 0.02(. Male gender and conversion from laparoscopic to open surgical technique had increased HR but did not reach statistical significance. Conclusion The presence of microscopic CD at the resection margins was not associated with disease recurrence. We found that male gender, perianal disease, laparoscopic approach, conversion to laparotomy and stapled anastomosis were associated with early disease recurrence. Our results support a conservative approach in the determination of the extent of resection in CD patients having ileocecal resection.

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