Inflammatory bowel diseases (IBD) are becoming more common in Asia, but epidemiologic data are lacking. The Asia-Pacific Crohn's and Colitis Epidemiology Study aimed to determine the incidence and phenotype of IBD in 8 countries across Asia and in Australia.We performed a prospective, population-based study of IBD incidence in predefined catchment areas, collecting data for 1 year, starting on April 1, 2011. New cases were ascertained from multiple overlapping sources and entered into a Web-based database. Cases were confirmed using standard criteria. Local endoscopy, pathology, and pharmacy records were searched to ensure completeness of case capture.We identified 419 new cases of IBD (232 of ulcerative colitis [UC], 166 of Crohn's disease [CD], and 21 IBD-undetermined). The crude annual overall incidence values per 100,000 individuals were 1.37 for IBD in Asia (95% confidence interval: 1.25-1.51; 0.76 for UC, 0.54 for CD, and 0.07 for IBD-undetermined) and 23.67 in Australia (95% confidence interval: 18.46-29.85; 7.33 for UC, 14.00 for CD, and 2.33 for IBD-undetermined). China had the highest incidence of IBD in Asia (3.44 per 100,000 individuals). The ratios of UC to CD were 2.0 in Asia and 0.5 in Australia. Median time from symptom onset to diagnosis was 5.5 months (interquartile range, 1.4-15 months). Complicated CD (stricturing, penetrating, or perianal disease) was more common in Asia than Australia (52% vs 24%; P =.001), and a family history of IBD was less common in Asia (3% vs 17%; P <.001).We performed a large-scale population-based study and found that although the incidence of IBD varies throughout Asia, it is still lower than in the West. IBD can be as severe or more severe in Asia than in the West. The emergence of IBD in Asia will result in the need for specific health care resources, and offers a unique opportunity to study etiologic factors in developing nations.Copyright © 2013 AGA Institute. Published by Elsevier Inc. All rights reserved.

The Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) initiative of the International Organization for the Study of Inflammatory Bowel Diseases (IOIBD) has proposed treatment targets in 2015 for adult patients with inflammatory bowel disease (IBD). We aimed to update the original STRIDE statements for incorporating treatment targets in both adult and pediatric IBD.Based on a systematic review of the literature and iterative surveys of 89 IOIBD members, recommendations were drafted and modified in 2 surveys and 2 voting rounds. Consensus was reached if ≥75% of participants scored the recommendation as 7 to 10 on a 10-point rating scale.In the systematic review, 11,278 manuscripts were screened, of which 435 were included. The first IOIBD survey (n = 39 on Crohn's disease and n = 36 on ulcerative colitis) identified the following targets as most important: clinical response and remission, endoscopic healing, and normalization of C-reactive protein/erythrocyte sedimentation rate and calprotectin. Fifteen recommendations were identified, of which 13 were endorsed (n = 70). STRIDE-II confirmed STRIDE-I long-term targets of clinical remission and endoscopic healing and added absence of disability, restoration of quality of life, and normal growth in children. Symptomatic relief and normalization of serum and fecal markers have been determined as short-term targets. Transmural healing in Crohn's disease and histological healing in ulcerative colitis are not formal targets but should be assessed as measures of the remission depth.STRIDE-II encompasses evidence- and consensus-based recommendations for treat-to-target strategies in adults and children with IBD. This frameworkshould be adapted to individual patients and local resources to improve outcomes.Copyright © 2020 AGA Institute. Published by Elsevier Inc. All rights reserved.

Although biological agents targeting tumor necrosis factor (TNF) alpha are effective in the management of Crohn's disease (CD), use of anti-TNF agents is often delayed until after failure of other treatment modalities, resulting in potentially long delays between diagnosis and initiation of infliximab or adalimumab. We aim to determine if early treatment with anti-TNF agents reduces the rate of surgical resection and clinical secondary loss of response in CD patients.A retrospective cohort study was conducted evaluating CD outpatients who were primary responders to anti-TNF therapy, on a maintenance regimen with infliximab or adalimumab from 2003 to 2014. Patients were stratified by time to first dose of anti-TNF therapy; early initiation was defined as starting anti-TNF therapy within 2 years of diagnosis. The primary outcome was occurrence of surgical resection or clinical secondary loss of response requiring dose escalation. Kaplan-Meier analysis was used to assess time to the primary outcomes.One hundred ninety CD patients met inclusion criteria (100 infliximab, 90 adalimumab). Median follow-up duration was 154.4 weeks (inter quartile range, 106.4-227.8). Fifty-three patients (27.9%) had early initiation of anti-TNF therapy. Fewer patients in the early initiation group required surgery (5.7% versus 30.7%, P < 0.001) or experienced clinical secondary loss of response (45.3% versus 67.2%, P = 0.006). In Kaplan-Meier analysis, early initiation of anti-TNF therapy prolonged time to surgery (P = 0.001) and secondary loss of response (P = 0.006).In CD patients, early initiation of infliximab or adalimumab within the first 2 years of diagnosis reduces the rate of surgery and secondary loss of response requiring dose escalation.

Internal fistula in Crohn's disease is a condition likely to require surgery, although few reports showed successful medical treatments such as anti-tumor necrosis factor (TNF) therapy. We performed a multicenter retrospective cohort study to investigate the outcome of anti-TNF therapy for internal fistula in Crohn's disease.Data were retrospectively collected from patients with Crohn's disease diagnosed with internal fistula treated with anti-TNF agents (infliximab or adalimumab) between January 2002 and November 2015. Need for surgery and fistula closure were assessed as primary and secondary endpoints. Cumulative rate of surgery was evaluated by the Kaplan-Meier analysis. Prognostic factors for the outcomes were also assessed by univariate and multivariate analyses.A total of 93 Crohn's disease cases were included in the study with a mean follow-up period of 1452.8 days. Fistula locations were entero-entero/colonic (n = 72, 77.4%), enterovesical (n = 16, 17.2%), or enterovaginal (n = 5, 5.4%). Cumulative surgery rate was 47.2%, and fistula closure rate was 27.0% at 5 years from the induction of anti-TNF agents. Lower Crohn's Disease Activity Index and shorter duration from the diagnosis of fistula were independently associated with the lower risk of surgery (P = 0.017 and 0.048, respectively). Single fistula was associated with the successful fistula closure. Second-line surgical treatments were mostly successful for anti-TNF failures.In the present retrospective cohort study, approximately half of patients with internal fistulas avoided surgery for long periods. It may be reasonable to treat quiescent single internal fistulas with anti-TNF agents soon after the diagnosis of internal fistulas.

Evaluate the cost-effectiveness of laparoscopic ileocaecal resection compared with infliximab in patients with ileocaecal Crohn's disease failing conventional therapy.A multicentre randomised controlled trial was performed in 29 centres in The Netherlands and the UK. Adult patients with Crohn's disease of the terminal ileum who failed >3 months of conventional immunomodulators or steroids without signs of critical strictures were randomised to laparoscopic ileocaecal resection or infliximab. Outcome measures included quality-adjusted life-years (QALYs) based on the EuroQol (EQ) 5D-3L Questionnaire and the Inflammatory Bowel Disease Questionnaire (IBDQ). Costs were measured from a societal perspective. Analyses were performed according to the intention-to-treat principle. Missing cost and effect data were imputed using multiple imputation. Cost-effectiveness planes and cost-effectiveness acceptability curves were estimated to show uncertainty.In total, 143 patients were randomised. Mean Crohn's disease total direct healthcare costs per patient at 1 year were lower in the resection group compared with the infliximab group (mean difference €-8931; 95% CI €-12 087 to €-5097). Total societal costs in the resection group were lower than in the infliximab group, however not statistically significant (mean difference €-5729, 95% CI €-10 606 to €172). The probability of resection being cost-effective compared with infliximab was 0.96 at a willingness to pay (WTP) of €0 per QALY gained and per point improvement in IBDQ Score. This probability increased to 0.98 at a WTP of €20 000/QALY gained and 0.99 at a WTP of €500/point of improvement in IBDQ Score.Laparoscopic ileocaecal resection is a cost-effective treatment option compared with infliximab.Dutch Trial Registry NTR1150; EudraCT number 2007-005042-20 (closed on 14 October 2015).© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.

Early Crohn's disease (CD) treatment involves anti-tumor necrosis factor (TNF) agents, while ileocecal resection (ICR) is reserved for complicated CD or treatment failure. We aimed to compare long-term outcomes of primary ICR and anti-TNF therapy for ileocecal CD.Using cross-linked nationwide registers, we identified all individuals diagnosed with ileal or ileocecal CD between 2003 and 2018, treated with ICR or anti-TNF agents within one year of diagnosis. The primary outcome was a composite of one or more of the following: CD-related hospitalization, systemic corticosteroid exposure, CD-related surgery, and perianal CD. We conducted adjusted Cox proportional hazards regression analyses and determined cumulative risk of different treatments following primary ICR or anti-TNF therapy.Of 16,443 individuals diagnosed with CD, 1,279 individuals fulfilled the inclusion criteria. Of these, 45.4% and 54.6% of individuals underwent ICR and received anti-TNF, respectively. The composite outcome occurred in 273 individuals (IR 110/1000 person years (PY)) in the ICR group and in 318 individuals (IR 202/1000 PY) in the anti-TNF group. The risk of the composite outcome was 33% lower with ICR, compared to anti-TNF (aHR 0.67; 95% CI 0.54, 0.83). ICR was associated with reduced risk of systemic corticosteroid exposure and CD-related surgery, but not other secondary outcomes. The proportion of individuals on IMM, anti-TNF, who underwent subsequent resection, or on no therapy 5 years post-ICR was 46.3%, 16.8%, 1.8%, and 49.7%, respectively.These data suggest that ICR may have a role as first-line therapy in CD management and challenge the current paradigm of reserving surgery for complicated CD refractory or intolerant to medications. Yet, given inherent biases associated with observational data, our findings should be interpreted and applied cautiously in clinical decision-making.Copyright © 2023 AGA Institute. Published by Elsevier Inc. All rights reserved.

The natural history of Crohn's disease is characterized by recurrent exacerbations. A small, but significant, number of pediatric patients with Crohn's disease are resistant to standard medical therapies. The goal of therapy in pediatric patients is not only to achieve and maintain clinical remission, but also to promote growth, development and improve quality of life. All of this needs to be achieved within a relatively short window of opportunity, before growth and development deficiencies become permanent. The standard therapy for pediatric patients with Crohn's disease consists of 5-aminosalicylic-acid compounds, antibiotics and enteral nutrition. Enteral nutrition has an excellent adverse-effect profile and, in addition to its therapeutic effect, positively impacts growth and nutritional status. Immunomodulating medications, such as azathioprine, 6-mercaptopurine and methotrexate, are frequently used to maintain remission, and to treat corticosteroid-dependent and perianal disease. Recently, biologic treatment with the anti-tumor-necrosis-factor-alpha antibody infliximab has dramatically changed the therapeutic approach. The long-term safety of this therapy still needs to be established. Limited data are available on other biologic therapies, which, at this point in time, are considered experimental and are only available through clinical trials.

We hypothesize that in children with Crohn's disease (CD) isolated to a single site, resection leads to clinical improvement, decreased medication requirements, and improved growth.A retrospective review was conducted of children with CD isolated to the terminal ileum undergoing operative intervention at Children's Hospital Colorado between 2002 and 2013.Twenty-six patients underwent ileocecetomy (mean age at diagnosis 14.1 ± 2.6 years; mean age at resection 15.7 ± 2.5 years; median follow-up 2 ± 1.5 years). Twenty-two (84.6%) patients reported clinical improvement and 17 (65.4%) were able to decrease the number or dosage of medications. Average weight increased from the 29th to the 45th percentile (P =.09) at 1 year and to the 56th percentile (P =.02) at 3 years post resection. Average body mass index increased from the 30th to the 48th and 49th percentile at 1 and 3 years (P <.05 for both), respectively. Height increased from the 39th percentile at the time of resection to the 51st percentile at 3 years (P = nonsignificant).Surgical resection of an isolated ileal segment in adolescents with CD allows for catch-up growth and reduction in medication requirements.Copyright © 2015 Elsevier Inc. All rights reserved.

The aim of this study was to investigate the therapeutic role of an elective ileocecal resection in children with active localized Crohn's disease.This was a retrospective multicenter study which included five European referral centers which included all children with Crohn's disease who underwent ileocecal surgery from 2000 to 2011 and had a minimum of 12 months follow-up.Altogether 68 patients fulfilled inclusion criteria. Median age at diagnosis was 13.7 years (6.6-17.9 years) and at surgery 15.2 years (8.6-18.5 years). Median duration of postoperative clinical remission was 20 months (3-95 months). Overall 54 patients (79.4%) were in remission one year after surgery and 38 (55.9%) during the total postsurgical follow up (median 30 months; range 12-95 months). Z score height for age significantly improved postoperatively in children who were at the time of surgery younger than 16 years of age (mean difference 0.232 SD; p=0.029). Cox proportional hazard regression model failed to indicate risk factors associated with postsurgical relapse.Elective ileocecal resection is a valid treatment option which should be considered in a subset of pediatric patients with localized Crohn's disease with the aim of achieving clinical remission and to improve growth.Copyright © 2015 Elsevier Inc. All rights reserved.

The aim of this study was to evaluate the results of surgery in children with Crohn disease (CD) not responding to medical therapy and establish whether surgery improves growth and nutrition.

We examined the impact of comorbidities on length of stay and total hospital charges for children and young adults with Crohn's Disease (CD) undergoing surgery.Patients (<21 years) were identified with a diagnosis of CD and an intraabdominal surgery in the Kids' Inpatient Database for the years 2006, 2009 and 2012. Length of stay (LOS) and total hospital charges (THC; USD$) were stratified by anemia, anxiety, depression and nutritional deficiency. National estimates were obtained using case weighting and multivariable linear regression was performed.We identified 3224 CD admissions with an intraabdominal surgery. The population was predominantly male, non-Hispanic white, and high school aged. There was an increase in LOS and THC for nutritional deficiency in all study years, and for depression and anemia in specific years. Multivariable linear regression revealed a 3.3-5.5 day increase in LOS associated with a comorbid diagnosis of nutritional deficiency. However, no increase in THC was seen for any comorbidity under evaluation.Behavioral health and, particularly, nutritional status have a significant impact on the care of children and young adults with CD. Nutritional deficiency, anemia, and depression resulted in increased LOS for those undergoing surgery. Improved presurgical management of comorbidities may reduce LOS for these patients.III.Copyright © 2019 Elsevier Inc. All rights reserved.

Colorectal cancer (CRC) is one of the major life-threatening complications in patients with Crohn's disease (CD). Previous studies of CD-associated CRC have involved only small numbers of patients, and no large series have been reported from Asia. The aim of this study was to clarify the prognosis and clinicopathological features of CD-CRC compared to sporadic CRC.A large nationwide database was used to identify patients with CD-CRC (n=233) and sporadic CRC (n=129,783) over a 40-year period, from 1980 to 2020. Five-year overall survival (OS), recurrence-free survival (RFS), and clinicopathological characteristics were investigated. The prognosis of CD-CRC was further evaluated in groups divided by colon cancer (CC) and anorectal cancer (RC). Multivariable Cox regression analysis was used to adjust for confounding by unbalanced covariables.Compared to sporadic cases, patients with CD-CRC were younger; more often had RC, multiple lesions, and mucinous adenocarcinoma; and had lower R0 resection rates. Five-year OS was worse for CD-CRC than for sporadic CRC (53.99% vs. 71.17%, P<0.001). Multivariable Cox regression analysis revealed that CD was associated with significantly poorer survival (HR 2.36, 95% CI: 1.54-3.62, P<0.0001). Evaluation by tumor location showed significantly worse 5-year OS and RFS of CD-RC compared to sporadic RC. Recurrence was identified in 39.57% of CD-RC cases and was mostly local.Poor prognosis of CD-CRC is attributable primarily to RC and high local recurrence. Local control is indispensable to improving prognosis.Copyright © 2023 by The American College of Gastroenterology.

The aim of our study was to conduct a systematic review and meta-analysis comparing the survival outcomes of IBD-associated and non-IBD-associated CRC.

One hundred thirty-two of 980 patients (13.5%) with Crohn's disease (CD) involving the colon, admitted to The Mount Sinai Hospital between 1959 and 1985, developed 175 colonic strictures. Thirty-three patients developed more than one stricture. The frequency was twice as great in colitis (19%) as in ileocolitis (11%). Ten malignant strictures were identified in nine patients (three ileocolitis, six colitis). One of these patients had three strictures (two malignant, and one benign), and two had two strictures (one malignant and one benign). The frequency of cancer in patients with stricture (6.8%) was higher than in those without stricture (0.7%, six of 848, p less than 0.001). There were no differences in clinical symptoms between patients with benign and malignant stricture. Seventeen of 165 benign strictures (10.3%) were long, extending over more than one anatomical segment of colon, but all 10 malignant strictures were short (p less than 0.0001). The age at the diagnosis of stricture was higher in the nine patients with malignant stricture than in the 123 patients with benign stricture (mean age 57.2 vs. 41.4 yr, respectively, p less than 0.01). The proportion of strictures that were malignant increased with duration of disease from 3.3% with less than 20 yr of CD, to 11% with CD of 20 yr or more. All nine patients with malignant stricture were treated surgically, and four of the nine died of colon cancer during a mean follow-up of 4.3 yr. Prognosis was worse in six other nonstricture cancers in this series, with five colon cancer deaths during mean follow-up of 1.6 yr. In view of the high rate of malignancy, 6.8% in this series, colonoscopy with biopsy is essential in Crohn's disease patients with colonic strictures, and surgery must be considered when a stricture cannot be fully assessed during colonoscopy.

The extent of surgical resection in inflammatory bowel disease (IBD) patients who develop colorectal cancer (CRC) is not prescribed by guidelines. We aim to evaluate, at a population level, the association of extent of surgical resection with survival outcomes.Using a validated Ontario registry of Crohn's disease (CD) and ulcerative colitis (UC) patients, we identified patients who underwent colorectal cancer resection between 2007 and 2015. Patient, tumor, and treatment factors, including type of surgical resection, were collected. Resections were grouped as segmental, total colectomy, and proctocolectomy. Multivariable cox proportional hazard regression was performed to identify factors associated with survival, including extent of surgical resection.Between 2007 and 2015, 84,694 patients had resections for CRC in the province of Ontario, 599 had ulcerative colitis (UC), and 366 had Crohn's disease (CD). Segmental resection was the most common operation performed and was more common in CD patients compared to UC (68% vs. 45.6%, p < 0.001). Five-year survival was 63.7% (95% CI 59.5-67.7) in UC patients and 57.5% (95% CI 51.9-62.7) in CD patients (p = 0.033). Multivariable analysis showed worse survival in patients undergoing total colectomy, compared to segmental resection [HR 1.70 (95% CI 1.31-2.21), p < 0.001]. There was no significant difference in survival between patients undergoing segmental resection and proctocolectomy [HR 0.99 (95% CI 0.78-1.27)]. This pattern was similar within the subtypes of IBD.In the setting of IBD-associated CRC, segmental resection and proctocolectomy are associated with similar survival outcomes in both UC and CD patients. Prospective study is essential to explore these findings.© 2021. The Society for Surgery of the Alimentary Tract.

Inflammatory bowel disease (IBD) patients are at increased risk of advanced neoplasia (high-grade dysplasia (HGD) or colorectal cancer (CRC)). We aimed to (1) assess synchronous and metachronous neoplasia following (sub)total or proctocolectomy, partial colectomy or endoscopic resection for advanced neoplasia in IBD and (2) identify factors associated with treatment choice.In this retrospective multicenter cohort study, we used the Dutch nationwide pathology databank (PALGA) to identify patients diagnosed with IBD and colonic AN between 1991 and 2020 in seven hospitals in the Netherlands. Logistic and Fine&Gray's subdistribution hazard models were used to assess adjusted subdistribution hazard ratios (asHR) for metachronous neoplasia and associations with treatment choice.We included 189 patients (HGD n=81; CRC n=108). Patients were treated with proctocolectomy (n=33), (sub)total colectomy (n=45), partial colectomy (n=56) and endoscopic resection (n=38). Partial colectomy was more frequently performed in patients with limited disease and older age, with similar patient characteristics between Crohn's disease and ulcerative colitis. Synchronous neoplasia was found in 43 patients (25.0%; (sub)total or proctocolectomy n=22, partial colectomy n=8, endoscopic resection n=13). We found a metachronous neoplasia rate of 6.1, 11.5 and 13.7 per 100 patient-years after (sub)total colectomy, partial colectomy and endoscopic resection, respectively. Endoscopic resection, but not partial colectomy, was associated with an increased metachronous neoplasia risk (asHR 4.16, 95% CI 1.64-10.54, P<0.01) compared to (sub)total colectomy.After confounder adjustment, partial colectomy yielded a similar metachronous neoplasia risk compared to (sub)total colectomy. High metachronous neoplasia rates after endoscopic resection underline the importance of strict subsequent endoscopic surveillance.Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.

There have been varying reports of mortality after intestinal resection for the inflammatory bowel diseases (IBDs). We performed a systematic review and meta-analysis of population-based studies to determine postoperative mortality after intestinal resection in patients with IBD.We searched Medline, EMBASE, and PubMed, from 1990 through 2015, to identify 18 articles and 3 abstracts reporting postoperative mortality among patients with IBD. The studies included 67,057 patients with ulcerative colitis (UC) and 75,971 patients with Crohn's disease (CD), from 15 countries. Mortality estimates stratified by emergent and elective surgeries were pooled separately for CD and UC using a random-effects model. To assess changes over time, the start year of the study was included as a continuous variable in a meta-regression model.In patients with UC, postoperative mortality was significantly lower among patients who underwent elective (0.7%; 95% confidence interval [CI], 0.6%-0.9%) vs emergent surgery (5.3%; 95% CI, 3.8%-7.4%). In patients with CD, postoperative mortality was significantly lower among patients who underwent elective (0.6%; 95% CI, 0.2%-1.7%) vs emergent surgery (3.6%; 95% CI, 1.8%-6.9%). Postoperative mortality did not differ for elective (P =.78) or emergent (P =.31) surgeries when patients with UC were compared with patients with CD. Postoperative mortality decreased significantly over time for patients with CD (P <.05) but not UC (P =.21).Based on a systematic review and meta-analysis, postoperative mortality was high after emergent, but not elective, intestinal resection in patients with UC or CD. Optimization of management strategies and more effective therapies are necessary to avoid emergent surgeries.Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.

The aim of this review was to examine current surgical treatments in patients with Crohn's disease (CD) and to discuss currently popular research questions.A literature search of MEDLINE (PubMed) was conducted using the following search terms: 'Surgery' and 'Crohn'. Different current surgical treatment strategies are discussed based on disease location.Several surgical options are possible in medically refractory or complex Crohn's disease as a last resort therapy. Recent evidence indicated that surgery could also be a good alternative in terms of effectiveness, quality of life and costs as first-line therapy if biologicals are considered, e.g. ileocolic resection for limited disease, or as part of combination therapy with biologicals, e.g. surgery aiming at closure of select perianal fistula in combination with biologicals. The role of the mesentery in ileocolic disease and Crohn's proctitis is an important surgical dilemma. In proctectomy, evidence is directing at removing the mesentery, and in ileocolic disease, it is still under investigation. Other surgical dilemmas are the role of the Kono-S anastomosis as a preventive measure for recurrent Crohn's disease and the importance of (non)conventional stricturoplasties.Surgical management of Crohn's disease remains challenging and is dependent on disease location and severity. Indication and timing of surgery should always be discussed in a multidisciplinary team. It seems that early surgery is gradually going to play a more important role in the multidisciplinary management of Crohn's disease rather than being a last resort therapy.

Abscesses, fistulas,hemorrhages and stenoses are common complications of inflammatory bowel diseases. This study provides an overview on various methods of radiological intervention and the clinical usefulness of these methods is analyzed.The success rate of percutaneous abscess drainage (PAD), embolisation of hemorrhages and dilatation of bowel stenoses is reviewed and current literature is addressed. Success rate is defined in terms of cure rate and need for subsequent surgery.After PAD, surgery can be avoided during the observation period in about 50% of patients with abscesses due to Crohn's disease and diverticulitis. Preoperative PAD reduces the degree of invasiveness and thus the risk of surgery. Abscess recurrence is found with the same frequency following surgery or PAD. Bowel dilatation can be performed both with radiological and with endoscopic guidance.Embolisation of GI-hemorrhage is technically feasible, but the indication should be limited to strictly selected cases.In treating abscesses and fistulas associated with Crohn's disease and diverticulitis, PAD is a valuable treatment option. Embolisation or dilatation are restricted to rare cares.

Postoperative intra-abdominal septic complications [IASCs] are the most feared risks of surgery for Crohn's disease[CD]. The risk factors for IASCs still remain controversial. The aim of this study was to assess the risk factors for IASCs in CD patients undergoing abdominal surgery.MEDLINE, Cochrane Library, and EMBASE were searched to identify observational studies reporting the risk factors for IASCs in CD patients. A meta-analysis was conducted to investigate the impact of various risk factors on IASCs in CD. The GRADE [Grading of Recommendations Assessment, Development and Evaluation] approach was used for quality assessment of evidence on outcome levels.This review included 15 studies evaluating 3807 patients undergoing 4189 operations. The meta-analyses found that low albumin levels (odds ratio [OR]: 1.93; 95% confidence interval [CI]: 1.362.75), preoperative steroids use [OR: 1.99; 95% CI: 1.54-2.57], a preoperative abscess [OR: 1.94; 95% CI: 1.263.0], previous surgery history [OR: 1.50; 95% CI: 1.151.97] may be risk factors for IASCs. There were no associations between anastomosis methods [OR: 0.94; 95% CI: 0.58-1.53], biologics therapy [OR: 1.29; 95% CI: 0.792.11], and immunomodulator use [OR: 1.07; 95% CI: 0.661.73] with the risk of IASCs. Due to observational design, the quality of evidence was regarded low or moderate for these risk factors by the GRADE approach.This meta-analysis provides some evidence that steroids use, previous surgical history, a preoperative abscess, and low albumin levels may be associated with higher rates of IASCs in CD. Knowledge about those risk factors may influence treatment and procedure-related decisions, and possibly reduce the ss rate.Copyright © 2015 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Postoperative intra-abdominal septic complications in patients with Crohn’s disease undergoing intestinal resection and anastomosis are frequent and difficult to manage.

Background: The impact of biologics on the risk of postoperative complications (PC) in inflammatory bowel disease (IBD) is still an ongoing debate. This lack of evidence is more relevant for ustekinumab and vedolizumab. Aims: To evaluate the impact of biologics on the risk of PC. Methods: A retrospective study was performed in 37 centres. Patients treated with biologics within 12 weeks before surgery were considered “exposed”. The impact of the exposure on the risk of 30-day PC and the risk of infections was assessed by logistic regression and propensity score-matched analysis. Results: A total of 1535 surgeries were performed on 1370 patients. Of them, 711 surgeries were conducted in the exposed cohort (584 anti-TNF, 58 vedolizumab and 69 ustekinumab). In the multivariate analysis, male gender (OR: 1.5; 95% CI: 1.2–2.0), urgent surgery (OR: 1.6; 95% CI: 1.2–2.2), laparotomy approach (OR: 1.5; 95% CI: 1.1–1.9) and severe anaemia (OR: 1.8; 95% CI: 1.3–2.6) had higher risk of PC, while academic hospitals had significantly lower risk. Exposure to biologics (either anti-TNF, vedolizumab or ustekinumab) did not increase the risk of PC (OR: 1.2; 95% CI: 0.97–1.58), although it could be a risk factor for postoperative infections (OR 1.5; 95% CI: 1.03–2.27). Conclusions: Preoperative administration of biologics does not seem to be a risk factor for overall PC, although it may be so for postoperative infections.

Intra-abdominal abscesses complicating Crohn’s disease [CD] are a challenging situation. Their management, during hospitalisation and after resolution, is still unclear.

Percutaneous drainage (PD) of Crohn's related abscesses is becoming popular with the development of techniques. We retrospectively analyzed the outcome of initial PD versus initial surgical drainage for intra-abdominal abscesses in Crohn's disease.Twenty-three patients of Crohn's disease complicated with intra-abdominal or pelvic abscesses treated in our institution between July 2001 and April 2010 were retrospectively identified from 188 patients with proven Crohn's disease. Outcome measures included abscess recurrence after different treatments, post-drainage complications, ultimate stoma creation, and subsequent surgery for Crohn's disease.Patients were divided into initial PD group (n = 10) and initial surgery group (n = 13): post-drainage complications were more common in initial surgery group (2/10 vs 9/13, P = 0.036), abscess recurred in three patients (2/10 vs 1/13, NS), and subsequent surgery was needed in 10 patients (6/10 vs 4/13, NS). Ultimate stoma creation were significantly more in initial surgery group (1/10 vs 9/13, P = 0.01).Initial PD group had lower rate of post-drainage complications and ultimate stoma creation compared to the initial surgery group. Although subsequent surgery may not be avoided after PD, it can provide safe anastomosis for resections. Long-term follow-up should be done to assess the outcome of PD.

Growing evidence has shown that there are significant advantages associated with the use of laparoscopic surgery for Crohn's disease (CD). However, the impact of preoperative exclusive enteral nutrition (EEN) on postoperative complications and CD recurrence following laparoscopic surgery have not been investigated.A total of 120 CD patients undergoing bowel resection with laparoscopic surgery were eligible for this study. Patient data were collected from a prospectively maintained database. Before laparoscopic surgery, 45 CD patients received EEN for at least 4 weeks, and 75 CD patients had no EEN. Postoperative complications, and endoscopic and clinical recurrence were subsequently measured and compared after laparoscopic surgery and during follow-up assessments.Patients who received EEN had significant improvements in their nutritional (albumin, prognostic nutritional index (PNI), and hemoglobin) and inflammatory (C-reactive protein) status after the EEN treatment prior to surgery (P < 0.05). Patients who received EEN also experienced fewer postoperative complications, decreased surgical site infections, and a lower comprehensive complication index (P < 0.05). The endoscopic recurrence rates 6 months after surgery were also decreased significantly in patients who received EEN (P < 0.05). However, the incidence of clinical recurrence was similar in the 2 groups at 1-year follow-up. Endoscopic recurrence was correlated with ileocolonic disease, EEN before surgery, and PNI (P < 0.05). PNI remained independently associated with endoscopic recurrence after surgery.Preoperative EEN for at least 4 weeks improved CD patients' nutritional and inflammatory status, which in turn reduced postoperative complications following laparoscopic surgery and endoscopic recurrence on follow-up.Copyright © 2019. Published by Elsevier Ltd.

Ileocaecal resection is the most common operation performed in Crohn’s disease. Our study aimed to identify the risk factors for anastomotic recurrence following primary ileocaecal resection.

The study examined whether urgency of surgical intervention affects postoperative outcomes in patients with Crohn's disease (CD) undergoing bowel resection.The review was conducted according to a predefined, published study protocol in Prospero which is an international database of prospectively registered systematic reviews in health. The study reported according to PRIMSMA guidelines. We searched Embase and Pubmed for articles reporting postoperative outcome after urgent and elective surgery in patients with CD undergoing bowel resection. Primary outcome variable was 30-day overall postoperative complications while secondary outcome variables were intraabdominal septic complications (IASCs), mortality, reoperation, and readmission. Assessment of bias was performed using Newcastle-Ottawa score. Two authors independently extracted data on each study, patients, and outcome measures.The search identified 22 studies in which 955 patients underwent urgent surgeries while 6518 patients underwent elective surgeries. Based on the quality assessment, 19 studies were classified as having high risk of bias, one study as having a medium risk of bias and 2 studies as having low risk of bias (≥ 8 stars). Random-effect metaanalysis showed urgent surgery was associated with ~ 40% increase in overall complications compared to elective surgery (RR = 1.43, 95% CI [1.09; 1.87], p = 0.010). IASCs also increased in patients who had urgent surgery (RR = 1.44, 95% CI [1.08; 1.92], p = 0.013). No significant difference was shown in mortality and readmission rates.Urgent bowel resection in patients with CD is associated with higher risk of overall postoperative complications and IASCs.

We sought to assess the evolution of Crohn's disease behavior in an American population-based cohort.Medical records of all Olmsted County, Minnesota residents who were diagnosed with Crohn's disease from 1970 to 2004 were evaluated for their initial clinical phenotype, based on the Montreal Classification. The cumulative probabilities of developing structuring and/or penetrating complications were estimated using the Kaplan-Meier method. Proportional hazards regression was used to assess associations between baseline risk factors and changes in behavior.Among 306 patients, 56.2% were diagnosed between the ages of 17 and 40 years. Disease extent was ileal in 45.1%, colonic in 32.0%, and ileocolonic in 18.6%. At baseline, 81.4% had nonstricturing nonpenetrating disease, 4.6% had stricturing disease, and 14.0% had penetrating disease. The cumulative risk of developing either complication was 18.6% at 90 days, 22.0% at 1 year, 33.7% at 5 years, and 50.8% at 20 years after diagnosis. Among 249 patients with nonstricturing, nonpenetrating disease at baseline, 66 changed their behavior after the first 90 days from diagnosis. Relative to colonic extent, ileal, ileocolonic, and upper GI extent were significantly associated with changes in behavior, whereas the association with perianal disease was barely significant.In a population-based cohort study, 18.6% of patients with Crohn's disease experienced penetrating or stricturing complications within 90 days after diagnosis; 50% experienced intestinal complications 20 years after diagnosis. Factors associated with development of complications were the presence of ileal involvement and perianal disease.Copyright © 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.

To examine the efficiency of exclusive enteral nutrition (EEN) in relieving inflammatory bowel stricture in patients with Crohn's disease (CD).Patients with CD usually develop bowel strictures due to transmural edema of intestinal wall, which can potentially be managed with conservative medical treatment. Previous studies showed that EEN therapy could induce clinical remission through its anti-inflammation effect.We achieved a prospective observational study. CD patients with inflammatory bowel stricture were preliminarily differentiated from a fibrous one, and further treated with EEN therapy for 12 weeks. Demographics and clinical variables were recorded. Nutritional (body mass index, albumin, pre-albumin, transferrin, etc.), inflammatory (C-reactive protein, erythrocyte sedimentation rate, white blood cell, etc.), and radiologic parameters (bowel wall thickness, luminal diameter, and luminal cross-sectional area) were evaluated at baseline, week 4, and week 12, respectively.Between May 2012 and January 2013, 65 patients with CD were preliminarily diagnosed with inflammatory bowel stricture and 6 patients were further excluded. Among the remaining 59 cases, 50 patients (84.7%) finished the whole EEN treatment, whereas the other 9 patients (15.3%) gained progressive bowel obstruction resulting in surgery. Intention-to-treat analyses showed that 48 patients (81.4%) achieved symptomatic remission, 35 patients (53.8%) achieved radiologic remission, and 42 patients (64.6%) achieved clinical remission. Among those patients who complete the whole EEN therapy, inflammatory, nutritional, and radiologic parameters improved significantly compared with baseline. Of note, the average luminal cross-sectional area at the site of stricture increased approximately 331% at week 12 (195.7 ± 18.79 vs. 59.09 ± 10.64 mm, P<0.001).EEN therapy can effectively relieve inflammatory bowel stricture in CD, which replenishes roles of enteral nutrition in the treatment of CD. Further studies are expected to investigate the underlying mechanisms of this effect in the future.

Laparoscopy combined with an enhanced recovery pathway (ERP) is widely considered to be the first-choice option for patients with colorectal cancer. However, no previous reports have focused on patients with Crohn's disease (CD) treated by laparoscopy and ERP.Twenty patients with CD underwent laparoscopic ileocecal resection with an ERP at two institutions. The ERP protocol included no bowel preparation nor fasting, no nasogastric tube, no abdominal drains, early removal of urinary catheter, early solid dietary intake and mobilization, opioid-sparing analgesia and restrictive fluid management. This group was compared with a matched historical control group of 70 CD patients who underwent laparoscopic ileocecal resection treated with conventional care.Compliance with the ERP was high (≥80 %) for all items except no drain placement. A significantly earlier return of bowel function (time to first flatus and stool) was observed in the ERP group. Mean postoperative and total length of stay were significantly shorter in the ERP group. Postoperative complications were similar in both groups.This is the first reported experience of laparoscopy with ERP in CD patients and suggests that optimized perioperative care combined with minimally invasive techniques may lead to further improvements in surgical outcomes for CD patients.

To compare 30-day postoperative complications in patients with inflammatory bowel disease (IBD) undergoing colorectal resection before and after implementation of a hospital-wide surgical care bundle (SCB) to prevent surgical site infection (SSI) followed by enhanced recovery protocol (ERP).Perioperative SCBs to prevent SSI after colectomy have evolved to include ERPs demonstrating reduced rates of SSI, ileus, and length of stay in colorectal surgical patients. IBD patients often present with more risk factors for postoperative complication like malnutrition or immunosuppression, and the impact of SCBs and ERPs in this population is understudied.Crohn's disease and ulcerative colitis patients undergoing elective bowel resection at a tertiary-level referral center from 2013 to 2018 were retrospectively evaluated. Postoperative complications at 30 days including SSI, ileus, and anastomotic leak were compared between pre-SCB/ERP, post-SCB, and post-SCB + ERP time periods using institutional ACS-NSQIP data. Pediatric (age < 18 years) and emergent cases were excluded.Out of 977 patients, 224 were pre-SCB/ERP, 517 post-SCB, and 236 post-SCB + ERP. Gender (P = 0.01), race (P = 0.02), body mass index (P = 0.04), immunosuppressant use (P = 0.01), wound classification (P < 0.001), malnutrition (P < 0.001), duration of procedure (P = 0.04), and procedure performed (P = 0.01) were significantly different between the three cohorts. A significant decrease in the rates of SSI (14.7% to 5.5%), ileus (20.1% to 8.9%), and anastomotic leak (4.7% to 0.0%) was demonstrated after implementation of SCB and ERP (P ≤ 0.01). On multivariable regression, the risk for postoperative SSI and ileus decreased significantly post-SCB + ERP (OR 0.39, CI 0.19-0.82 and OR 0.45, CI 0.24-0.84, respectively).SCB and ERP implementation was associated with decreased rates of postoperative SSI, ileus, and anastomotic leak for IBD patients undergoing elective bowel resection.

Enhanced Recovery After Surgery [ERAS] is widely adopted in patients undergoing colorectal surgery, with demonstrated benefits. Few studies have assessed the feasibility, safety, and effectiveness of ERAS in patients with inflammatory bowel diseases [IBD]. The aim of this study was to investigate the current adoption and outcomes of ERAS in IBD.

Although it is commonly reported that IBD patients are at increased risk for venous thromboembolic events, little real-world data exist regarding their postoperative incidence and related outcomes in everyday practice.We aimed to identify the rate of venous thromboembolism and modifiable risk factors within a large cohort of surgical IBD patients.We performed a retrospective review of IBD patients who underwent colorectal procedures.Patient data were obtained from the American College of Surgeons National Surgical Quality Improvement Program 2004 to 2010 Participant Use Data Files.The primary outcomes measured were short-term (30-day) postoperative venous thromboembolism (deep vein thrombosis and pulmonary embolism). Clinical variables were analyzed by univariate and multivariate analyses to identify modifiable risk factors for these events.A total of 10,431 operations were for Crohn's disease (52.1%) or ulcerative colitis (47.9%), and 242 (2.3%) venous thromboembolic events occurred (178 deep vein thromboses, 46 pulmonary embolisms, 18 both) for a combined rate of 1.4% in Crohn's disease and 3.3% in ulcerative colitis. Deep vein thrombosis and pulmonary embolism each occurred at a mean of 10.8 days postoperatively (range for each, 0-30 days). A multivariate model found that bleeding disorder, steroid use, anesthesia time, emergency surgery, hematocrit <37%,malnutrition, and functional status were potentially modifiable risk factors that remained associated (p < 0.05) with venous thromboembolism on regression analysis. Patients with thromboembolism had longer length of stay (18.8 vs 8.9 days), more complications (41% vs 18%), and a higher risk of death (4% vs 0.9%).This study was limited by its retrospective design and its limited generalizability to nonparticipating hospitals.Inflammatory bowel disease patients are at increased risk for postoperative venous thromboembolism. Reducing preoperative anemia, steroid use, malnutrition, and anesthesia time may also reduce venous thromboembolism in this at-risk population. Risk-reducing, preventative strategies are needed in this at-risk population.

Venous thromboembolism after abdominal surgery occurs in 2% to 3% of patients with Crohn's disease and ulcerative colitis. However, no evidence-based guidelines currently exist to guide postdischarge prophylactic anticoagulation.We sought to determine the use of postoperative postdischarge venous thromboembolism chemical prophylaxis, 90-day venous thromboembolism rates, and factors associated with 90-day thromboembolic events in IBD patients following abdominal surgery.This was a retrospective evaluation of an administrative database.Data were obtained from Optum Labs Data Warehouse, a large administrative database containing claims on privately insured and Medicare Advantage enrollees.Seven thousand seventy-eight patients undergoing surgery for Crohn's disease or ulcerative colitis were included in the study.Primary outcomes were rates of postdischarge venous thromboembolism prophylaxis and 90-day rates of postdischarge thromboembolic events. In addition, patient clinical characteristics were identified to determine predictors of postdischarge venous thromboembolism.Postdischarge chemical prophylaxis was given to only 0.6% of patients in the study. Two hundred thirty-five patients (3.3%) developed a postdischarge thromboembolic complication. Postdischarge thromboembolism was more common in patients with ulcerative colitis than with Crohn's disease (5.8% vs 2.3%; p < 0.001). Increased rates of venous thromboembolism were seen in patients undergoing colectomy or proctectomy with simultaneous stoma creation compared with colectomy or proctectomy alone (5.8% vs 2.1%; p < 0.001). The strongest predictors of thromboembolic complications were stoma creation (adjusted OR, 1.95; 95% CI, 1.34-2.84), J-pouch reconstruction (adjusted OR, 2.66; 95% CI, 1.65-4.29), preoperative prednisone use (adjusted OR, 1.57; 95% CI, 1.19-2.08), and longer length of stay (adjusted OR, 1.89; 95% CI, 1.41-2.52).This study is limited by its retrospective design.The use of postdischarge venous thromboembolism prophylaxis in this patient sample was infrequent. Development of evidence-based guidelines, particularly for high-risk patients, should be considered to improve the outcomes of IBD patients undergoing abdominal surgery.

Patients with inflammatory bowel disease (IBD) are at increased risk of postoperative venous thromboembolism (VTE) following major abdominal surgery. The pathogenesis is multifactorial and not fully understood. A combination of pathophysiology, patient and surgical risk factors increase the risk of postoperative VTE in these patients. Despite being at increased risk, IBD patients are not regularly prescribed extended pharmacological thromboprophylaxis following colorectal surgery. Currently, there is a paucity of evidence-based guidelines. Thus, the aim of this review is to evaluate the role of extended pharmacological thromboprophylaxis in IBD patients undergoing colorectal surgery.A search of Ovid Medline, EMBASE and PubMed databases was performed. A qualitative analysis was performed using 10 clinical questions developed by colorectal surgeons and a thrombosis haematologist. The Newcastle-Ottawa Scale was utilized to assess the quality of evidence.A total of 1229 studies were identified, 38 of which met the final inclusion criteria (37 retrospective, one case-control). Rates of postoperative VTE ranged between 0.6% and 8.9%. Patient-specific risk factors for postoperative VTE included ulcerative colitis, increased age and obesity. Surgery-specific risk factors for postoperative VTE included open surgery, emergent surgery and ileostomy creation. Patients with IBD were more frequently at increased risk in the included studies for postoperative VTE than patients with colorectal cancer. The risk of bias assessment demonstrated low risk of bias in patient selection and comparability, with variable risk of bias in reported outcomes.There is a lack of evidence regarding the use of extended pharmacological thromboprophylaxis in patients with IBD following colorectal surgery. As these patients are at heightened risk of postoperative VTE, future study and consideration of the use of extended pharmacological thromboprophylaxis is warranted.Colorectal Disease © 2019 The Association of Coloproctology of Great Britain and Ireland.

This prospective study assessed the feasibility of laparoscopic ileocolonic resection for complex Crohn's disease, i.e., recurrence or complication from abscess and/or fistula, and compared postoperative outcomes in patients with and without complex Crohn's disease.Between November 1998 and August 2007, 124 laparoscopic ileocolonic resections were attempted for Crohn's disease: 54 patients with complex Crohn's disease (group I) and 70 patients without complex Crohn's disease (group II). Postoperative mortality and morbidity were compared between group I and group II.Indications for surgery in group I included fistula (43 percent), abscess (30 percent), and recurrent disease after ileocolonic resection (27 percent). Complex Crohn's disease was significantly associated with increased mean (standard deviations) operative time [214 (13) vs. 191(53) minutes, P < 0.05), increased conversion rate to open procedure (37 percent vs. 14 percent, P < 0.01), and increased use of temporary stoma (39 percent vs. 9 percent, P < 0.001). No patients died. Overall postoperative morbidity was similar between both groups [17 percent vs. 17 percent, P = not significant (NS)], including major surgical postoperative complications (7 percent vs. 6 percent, P = NS). Mean (SD) hospital stay was not statistically different between both groups [8 (3) vs. 7 (3) days, P = NS].This large comparative study suggested that laparoscopic ileocolonic resection for complex Crohn's disease was feasible and safe with good postoperative outcomes. In our experience, complex Crohn's disease does not appear as a contraindication to a laparoscopic approach.

To identify preoperative characteristics to help in selecting laparoscopy or laparotomy in Crohn disease (CD).Laparoscopy in CD is associated with high rates of conversion.All patients undergoing abdominal surgery for CD in 2004 to 2016 by the senior author. Patients operated by laparoscopy, laparotomy, and converted to open were compared.Four hundred fifty-eight procedures were performed in 427 patients [F:M 1:1; median age = 41 (12-95) yrs], through laparotomy (n = 157, 34%) or laparoscopy (n = 301, 66%). Laparotomy rates decreased over time. Concomitant surgical procedures requiring laparotomy continued to dictate an open approach throughout the study. Sixty-five cases (21.6%) required conversion to laparotomy which occurred within 15' from start of case in 77%. Most common reasons for conversion included dense adhesions (34%), pelvic sepsis with fistulizing disease (26%), large inflammatory mass (18%), and thickened mesentery (9%). After multivariate analysis, predictive factors for conversion included recurrent disease after previous small bowel resection, thickened mesentery, large inflammatory mass, and extensive disease.Despite the increasing experience with laparoscopy in CD, one-fifth of selected cases still need conversion. Recurrent disease with dense adhesions, pelvic sepsis with fistulizing disease, large inflammatory mass, and thickened mesentery are all conditions predisposing to a conversion. When the severity of these conditions is known preoperatively or a simultaneous procedure requires a laparotomy, an open approach should be considered; if laparoscopy is selected, conversion to laparotomy can be decided early in the performance of the case.

Strictureplasty (SPX) conserves bowel length and minimizes the risk of developing short bowel syndrome in patients undergoing surgery for Crohn's disease (CD). However, SPX may be associated with a higher risk of recurrence compared with bowel resection (BR).We sought to compare morbidity and recurrence following SPX and BR in patients with fibrostenotic CD.A systematic review was performed according to PRISMA and MOOSE guidelines. Observational studies that compared outcomes of CD patients undergoing either SPX or BR were identified. Log hazard ratios (InHR) for recurrence-free survival (RFS) and their standard errors were calculated from Kaplan-Meier plots or Cox regression models and pooled using the inverse variance method. Dichotomous variables were pooled as odds ratios (OR) using the Mantel-Haenszel method. Continuous variables were pooled as weighted mean differences.Twelve studies of 1026 CD patients (SPX n = 444, 43.27%; BR with or without SPX n = 582, 56.72%) were eligible for inclusion. There was an increased likelihood of disease recurrence with SPX than with BR (OR 1.61; 95% CI, 1.03, 2.52; p = 0.04; I = 0%). Patients who had a SPX alone had a significantly reduced RFS than those who underwent BR (HR 1.47; 95% CI, 1.08, 2.01; p = 0.02; I = 0%). There was no difference in morbidity between the groups (OR 0.58; 95% CI, 0.26, 1.28; p = 0.18; I = 0%).SPX should only be performed in those patients with Crohn's strictures that are at high risk for short bowel syndrome and intestinal failure; otherwise, BR is the favored surgical technique for the management of fibrostenotic CD.

The optimal surgical approach to extensive Crohn's disease (CD) terminal ileitis is debated. To date, no studies have directly compared the short- and long-term outcomes of modified side-to-side isoperistaltic strictureplasty over the valve (mSSIS) to traditional ileocecal resection.A retrospective, observational, comparative study was conducted in consecutive CD patients operated for extensive involvement of the terminal ileum (≥ 20 cm). Ninety-day postoperative morbidity was assessed using the comprehensive complication index (CCI). Surgical recurrence was defined as the need for any surgical intervention related to CD during the follow-up period. Endoscopic remission was defined as ≤ i2a, according to the modified Rutgeerts score. Deep remission was defined as the combination of endoscopic remission and absence of clinical symptoms. Perioperative factors related to clinical recurrence were evaluated.Eighty-seven patients were included (47 (54%) ileocecal resection and 40 (46%) mSSIS). Median follow-up was 56 (IQR 34.7-94.4) and 72 (IQR 48.3-87.2) months for resection and mSSIS, respectively (p < 0.001). No mortality occurred. Mean CCI was 9.1 vs 8.5 for ileocecal resection and mSSIS, respectively (p = 0.48). Throughout the follow-up, 8 patients in the resection group (17%) and 5 patients in the mSSIS group (12.5%) experienced surgical recurrence (p = 0.393). Thirty-seven (92.5%) of patients kept the mSSIS. No difference in deep remission was observed (41% vs 22.5%, p = 0.34).Modified SSIS seems to be non-inferior in terms of safety, recurrence, and durability to traditional resections with the advantage of mitigating the risk of a short bowel syndrome. Larger prospective studies are required to confirm these findings.

Internal fistulas occur in 5-10% of patients with Crohn's disease. The clinical presentation of each of the three main types of internal fistulas--enteroenteric, enterovaginal, and enterovesical fistulas--is important in determining the best management. Asymptomatic fistulas usually require no treatment, but fistulas that cause severe or persistent symptoms necessitate intervention. Previously regarded as a surgical condition requiring resection, some internal fistulas are amenable to a more conservative approach involving medical therapy, surgical repair, or both. So far, there have not been any prospective studies designed specifically to assess the efficacy of a medical treatment of internal fistulas, and information about treatment results is gleaned from trials in which patients with internal fistulas have been included and from retrospective reports. Drugs that have been reported to close internal fistulas partially or completely include azathioprine, 6-mercaptopurine, mycophenolate mofetil, cyclosporine A, tacrolimus, and infliximab. Reparative surgical techniques include transrectal and transvaginal mucosal advancement flaps, cutaneous advancement flap, and anal stricturectomy in combination with a rectal mucosal advancement sleeve. Prospective trials of medical therapy and combination medical and surgical therapy for internal fistulas are needed to provide evidence to support the use of these new therapeutic approaches.

Ileosigmoid fistulas are found in Crohn's disease and may present a surgical dilemma.This study was designed to examine surgical practice to determine types of intervention, enumerate complications, and elicit guidelines for surgical management.The medical records of patients with ileosigmoid fistula and Crohn's disease from 1975 to 1995 were reviewed.Ninety patients (44 men) were studied. A preoperative diagnosis of ileosigmoid fistula was made in 77 percent of patients. Sigmoid repair was performed in 43 patients (47.8 percent), sigmoid resection in 32 patients (35.6 percent), 12 patients (13.3 percent) underwent more extensive procedures, and 3 patients (3.3 percent) either had surgery elsewhere or were observed. The fistula was never directly responsible for a stoma. The repair and resection groups were similar with respect to age, length of Crohn's disease, and preoperative symptoms. There was no significant difference between groups in the incidence of postoperative complications; there were no postoperative deaths. Average length of stay was 8.3 days following repair and 9.9 days after resection. Reasons for resection included significant purulence or inflammation, a large fistula defect, a defect on the mesenteric border of the sigmoid, and active sigmoid Crohn's disease. Surgeon's assessment of the presence of Crohn's disease in the sigmoid correlated with pathologic examination and was aided by knowledge of recent endoscopic appearance and biopsy results; intraoperative frozen section and colonoscopy were helpful in distinguishing serosal inflammation from active Crohn's disease.Contrast studies identified 77 percent of ileosigmoid fistulas preoperatively. Performing repair rather than resection does not increase the risk of complications, if standard surgical principles are followed. Preoperative or intraoperative endoscopy assists the surgical evaluation of the sigmoid.

This study was conducted to report the short- and long-term outcomes of surgery for coloduodenal fistula in Crohn's disease and explore the effect of preoperative optimization on surgical outcome.This is a retrospective review of 34 patients with coloduodenal fistula complicating Crohn's disease between Jan 2008 and May 2015. Demographic information, preoperative management, and intraoperative and postoperative outcome data were collected.Primary duodenal repair was carried out in 33 patients (13 with duodenal defect >3 cm), and bypass surgery was performed in one patient with duodenal stenosis. Patients undergoing preoperative optimization (n = 25) had decreased postoperative major (24.0 vs. 87.5 %, P = 0.005) and intra-abdominal septic (20.0 vs. 75.0 %, P = 0.008) complications compared to patients with emergent/semi-emergent surgery (n = 8). No duodenal stenosis occurred on a median follow-up of 22.5 months. Patients with duodenum-ileocolic anastomosis fistula had longer postoperative stay (14.0 vs. 10.0 days, P = 0.032) and increased possibility of refistulization of the duodenum on follow-up (30.0 vs. 0 %, P = 0.031) compared with those with spontaneous duodenum-colonic fistula.Primary duodenal repair can be safely performed in coloduodenal fistula in Crohn's disease provided there was no duodenal stenosis, even for large duodenal defects. Preoperative optimization is associated with reduced postoperative complications. Patients with duodenum-ileocolic anastomosis fistula are more likely to have duodenum fistula recurrence compared to those with spontaneous duodenum-colonic fistula.

Entero-urinary fistulas (EUF) are a rare complication of Crohn's disease (CD), observed in 1.6 to 7.7%. The management of EUF complicating CD is challenging. We aimed to report the outcome and surgical management of EUF in CD.A retrospective chart review was performed in all CD patients with EUF who underwent surgery in our center between January 2012 and December 2021. Patient demographics, preoperative optimization, surgical management, postoperative complications, and follow-up information were collected from a prospectively maintained database.A total of 74 eligible patients were identified. The median interval between CD diagnosis and EUF diagnosis was 2 (0.08-6.29) years. Patients with EUF presented with pneumaturia (75.68%), urinary tract infections (72.97%), fecaluria (66.22%), and hematuria (6.76%). Fistulae originated most commonly from the ileum (63.51%), followed by the colon (14.86%), the rectum (9.46%), the cecum (2.70%), and multiple sites (9.46%). The EUF symptoms, weight, nutritional status, laboratory results were significantly improved after preoperative optimization. The absence of EUF symptoms was observed in 42 patients after the optimization and only 9 of which required bladder repair. However, 19 of 32 patients whose symptoms did not resolve required bladder repair (P = 0.001). Only 1 patient developed a bladder leakage in the early postoperative period and 3 patients experienced recurrent bladder fistula.Surgical management of EUF complicating CD is effective and safe, with a low rate of postoperative complication and EUF recurrence. Preoperative optimization, which is associated with the resolution of urinary symptoms and improved surgical outcomes, should be recommended.© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.

Early ileocolonoscopy allows detection of recurrence after surgically induced remission of Crohn's disease (CD). Unequivocal histologic markers predicting recurrence have not been identified. We assessed the predictive value of neural lesions for early endoscopic CD recurrence and long-term reintervention risk.Ileocolonic resection specimens from 59 patients with CD and 21 control patients were histologically scored for typical inflammatory bowel disease lesions, neural hypertrophy, and presence and severity of inflamed ganglia and nerve bundles. Endoscopic recurrence was determined at 3 months in all patients and at 1 year in 32 patients as part of 2 prospective clinical trials.Myenteric plexitis of the proximal resection margin was present in 32 patients with CD (54%) in absence of surrounding inflammation. Patients with this feature had a higher endoscopic recurrence (Rutgeerts score >/=2) at 3 months (75% vs 41%; odds ratio, 4.36; 95% confidence interval, 1.44-13.23; P =.008) and at 1 year (93% vs 59%; odds ratio, 9.80; 95% confidence interval, 1.04-92.70; P =.041) and had a trend toward an earlier reintervention (mean, 7.00 vs 5.30 years; P =.174). The severity of myenteric plexitis in the proximal resection margin correlated with the severity of endoscopic recurrence at 3 months (r = 0.334, P =.010) and 1 year (r = 0.560, P =.001). Myenteric plexitis was the only consistent predictor of endoscopic recurrence.The presence of myenteric plexitis in proximal margins of ileocolonic resection specimens is predictive of early endoscopic CD recurrence.

The aims of the present study were to examine the density of lymphatic vessels in the mesentery and to assess the predictive value of the mesenteric lymphatic vessel density for postoperative clinical recurrence.Ileocolonic resection specimens were obtained from 53 patients with Crohn's disease and 10 non-inflammatory bowel disease control subjects. Mesentery adipose tissues adjacent to the bowel wall were used for the histological quantification of lymphatic vessels using immunohistochemistry with the D2-40 antibody. The relationships between lymphatic vessel density and disease behavior, the presence of granulomas, the presence of creeping fat, and postoperative clinical recurrence were assessed.Median lymphatic vessel density in the mesentery adjacent to inflamed or non-inflamed intestine was lower in control subjects than in Crohn's disease patients (2.13‰; interquartile range [IQR], 1.83-2.61; 8.34‰; IQR, 6.39-10.22; 4.43‰; IQR, 3.32-5.78; P ˂ 0.001). Increased mesenteric lymphatic vessel density was significantly associated with stricturing behavior, the presence of intestinal granulomas, the presence of creeping fat, and bowel thickness. Interestingly, patients with disease recurrence had an increased mesenteric lymphatic vessel density of the proximal mesenteric margin at the time of resection compared with those who did not have disease recurrence (6.23‰; IQR, 5.43-6.75 vs. 3.28‰; IQR, 2.93-4.29; P ˂ 0.001).In addition to its correlation with disease behavior, bowel thickness, and the presence of intestinal granulomas and creeping fat, increased mesenteric lymphatic vessel density in the proximal margin is predictive of early clinical recurrence after surgery in patients with Crohn's disease.

The pathogenesis and risk factors for early postoperative endoscopic recurrence of Crohn's disease [CD] remain unclear. Thus, this study aimed to identify whether histological inflammation at the resection margins after an ileocaecal resection influences endoscopic recurrence.We have prospectively followed up patients with CD who underwent ileocaecal resection at our hospital between January 2012 and January 2018. The specimens were histologically analysed for inflammation at both of the resection margins [ileal and colonic]. We evaluated whether histological results of the resection margins are correlated with endoscopic recurrence of CD based on colonoscopy 6 months after ileocaecal resection. Second, we assessed the influence of known risk factors and preoperative therapy on endoscopic recurrence of CD.A total of 107 patients were included in our study. Six months after ileocaecal resection, 23 patients [21.5%] had an endoscopic recurrence of CD. The histological signs of CD at the resection margins were associated with a higher endoscopic recurrence [56.5% versus 4.8%, p < 0.001]. Disease duration from diagnosis to surgery [p = 0.006] and the length of the resected bowel [p = 0.019] were significantly longer in patients with endoscopic recurrence. Smoking was also proved to be a risk factor for endoscopic recurrence [p = 0.028].Histological inflammation at the resection margins was significantly associated with a higher risk of early postoperative endoscopic recurrence after an ileocaecal resection for CD.© European Crohn’s and Colitis Organisation (ECCO) 2019.

Despite significant advances in the medical management of Crohn's disease, many patients will require intestinal resection during their lifetime. It is disappointing that many will also develop disease recurrence.The current study utilizes meta-analytical techniques to determine the effect of positive histological margins at the time of index resection on disease recurrence.Embase, Medline, PubMed, PubMed Central, and Cochrane databases were searched using a Boolean search algorithm for articles published up to August 2017.Meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Databases were searched for studies reporting the outcomes for patients with Crohn's disease undergoing primary resection that correlated resection margin status with disease recurrence. Results were reported as pooled ORs with 95% CI.A total of 176 citations were reviewed; 18 studies comprising 1833 patients were ultimately included in the analysis, with a mean rate of histopathological margin positivity of 41.7 ± 17.4% and a pooled mean follow-up of 69 ± 39 months. Histopathological margin positivity was associated with a higher rate of overall recurrence (OR, 1.7; 95% CI, 1.3-2.1; p < 0.001), clinical recurrence (OR, 1.7; 95% CI, 1.0-2.8; p = 0.04), and anastomotic recurrence (OR, 1.6; 95% CI, 1.0-2.3; p = 0.03). In studies reporting plexitis specifically at the resection margin, there was an increase in recurrence (OR, 2.3; 95% CI, 1.1-4.9; p = 0.02).The definitions of histological margin positivity and postoperative recurrence vary between the studies and follow-up durations vary.The presence of involved histological margins at the time of index resection in Crohn's disease is associated with recurrence, and plexitis shows promise as a marker of more aggressive disease. Further studies with homogeneity of histopathological and recurrence reporting are required.

Concomitant lesions in the small intestine are common in Crohn's disease (CD). This study aimed to detect the incidence of small bowel (SB) lesions in patients undergoing surgical resection for symptomatic ileocolic disease and whether concomitant SB lesions are associated with reoperation due to recurrent CD.In this observational, historical cohort study, consecutive patients with CD undergoing primary ileocolic resection (ICR) from 2007 to 2019 were included. Clinical variables and intraoperative findings were extracted from a prospectively maintained database and analyzed by Cox proportional hazards regression models for identifying risk factors of reoperation.Of the 404 patients included, there were 202 (50%) patients having concomitant SB lesions, and 108 of them underwent concurrent surgical intervention for SB lesions whereas 94 did not. The presence of concomitant SB lesions was a risk factor for reoperation (p = 0.041). Subgroup analysis indicated that patients with concomitant uncomplicated SB lesions left in situ had a comparable rate of reoperation (p = 0.605) whereas patients having concomitant complicated SB lesions undergoing simultaneous surgical intervention showed a higher reoperation rate (P = 0.006) when compared with those without concomitant SB lesions. Interestingly, the adverse effects of concomitant SB lesions can be reversed in the setting of postoperative anti-TNF agents [HR 0.2; 95% CI (0.04-0.9); P=0.040].Concomitant SB lesion(s), especially those complicated lesions, could be a risk factor for postoperative surgical recurrence in patients undergoing ICR. Active postoperative management strategies such as anti-TNF agents should be provided for these patients.© 2022. The Society for Surgery of the Alimentary Tract.

This trial aimed to provide randomized controlled data comparing Kono-S anastomosis and stapled ileocolic side-to-side anastomosis.Recently, a new antimesenteric, functional, end-to-end, hand-sewn ileocolic anastomosis (Kono-S) has shown a significant reduction in endoscopic recurrence score and surgical recurrence rate in Crohn disease (CD).Randomized controlled trial (RCT) at a tertiary referral institution. Primary endpoint: endoscopic recurrence (ER) (Rutgeerts score ≥i2) after 6 months. Secondary endpoints: clinical recurrence (CR) after 12 and 24 months, ER after 18 months, and surgical recurrence (SR) after 24 months.In all, 79 ileocolic CD patients were randomized in Kono group (36) and Conventional group (43). After 6 months, 22.2% in the Kono group and 62.8% in the Conventional group presented an ER [P < 0.001, odds ratio (OR) 5.91]. A severe postoperative ER (Rutgeerts score ≥i3) was found in 13.8% of Kono versus 34.8% of Conventional group patients (P = 0.03, OR 3.32). CR rate was 8% in the Kono group versus 18% in the Conventional group after 12 months (P = 0.2), and 18% versus 30.2% after 24 months (P = 0.04, OR 3.47). SR rate after 24 months was 0% in the Kono group versus 4.6% in the Conventional group (P = 0.3). Patients with Kono-S anastomosis presented a longer time until CR than patients with side-to-side anastomosis (hazard ratio 0.36, P = 0.037). On binary logistic regression analysis, the Kono-S anastomosis was the only variable significantly associated with a reduced risk of ER (OR 0.19, P < 0.001). There were no differences in postoperative outcomes.This is the first RCT comparing Kono-S anastomosis and standard anastomosis in CD. The results demonstrate a significant reduction in postoperative endoscopic and clinical recurrence rate for patients who underwent Kono-S anastomosis, and no safety issues.ClinicalTrials.gov ID NCT02631967.

Patients with Crohn’s disease (CD) after ileocolic resection may develop an endoscopic postoperative recurrence (ePOR) that reaches 40% to 70% of incidence within 6 months. Recently, there has been growing interest in the potential effect of anastomotic configurations on ePOR. Kono-S anastomosis has been proposed for reducing the risk of clinical and ePOR. Most studies have assessed the association of ileocolonic anastomosis and ePOR individually, while there is currently limited data simultaneously comparing several types of anastomosis. Therefore, we performed a systematic review and meta-analysis to assess the impact of different ileocolonic anastomosis on ePOR in CD.

Postoperative recurrence is a major concern in Crohn’s disease. The Kono-S anastomosis has been described to reduce the rate of recurrence. However, the level of evidence for its effectiveness remains low. The KoCoRICCO study aimed to compare outcomes between Kono-S anastomosis and conventional anastomosis in two nationwide, prospective cohorts.

Anastomotic complications occur more frequently in patients with Crohn's disease leading to postoperative intra-abdominal septic complications (IASC). Patients with IASC often require re-operation or drainage to control the sepsis and have an increased frequency of disease recurrence. The aim of this article was to examine the factors affecting postoperative IASC in Crohn's disease after anastomoses, since some risk factors remain controversial. Studies investigating IASC in Crohn's operations were included, and all risk factors associated with IASC were evaluated: nutritional status, presence of abdominal sepsis, medication use, Crohn's disease type, duration of disease, prior operations for Crohn's, anastomotic technique, extent of resection, operative timing, operative length, and perioperative bleeding. In this review, the factors associated with an increased risk of IASC are preoperative weight loss, abdominal abscess present at time of surgery, prior operation, and steroid use. To prevent IASC in Crohn's patients, preoperative optimization with nutritional supplementation or drainage of abscess should be performed, or a diverting stoma should be considered for patients with multiple risk factors.

Patients with Crohn's disease undergoing ileocolectomy and primary anastomosis are often at increased risk of anastomotic leak. We aimed to determine whether diverting ileostomy was protective against anastomotic leak after ileocolic resection for Crohn's disease using a large international registry.We analysed the National Surgical Quality Improvement Program Colectomy Module from 2012 to 2016. Multivariable logistic regression analysis and propensity-score matching were used to identify independent risk factors for leak, and to test the hypothesis that diverting ileostomy was protective against anastomotic leakage.A total of 4172 [92%] patients underwent primary anastomosis, and 365 [8%] underwent anastomosis plus ileostomy. The leak rates in the two groups were 4.5% and 2.7%, [p = 0.12], respectively. Multivariate analysis indicated ileostomy omission, emergency surgery, smoking, inpatient status, wound classification 3 or 4, weight loss, steroid use, and prolonged operative time were independently associated with leak. Patients with 0-6 risk factors had leak rates of 1.6%, 2.7%, 4.3%, 6.7%, 8.8%, 11.5%, and 14.3% [p ≤ 0.001], respectively. Following propensity-score matching, ileostomy reduced the risk of leak rate by 55% [p = 0.005]. Patients with primary anastomosis who leaked most frequently required reoperation [57.8%], but anastomosis plus ileostomy patients who leaked most frequently were managed by percutaneous drainage [70%], p = 0.04.After ileocolic resection for Crohn's disease, anastomotic leak may be predicted by simple addition of risk factors. We found that diverting ileostomy mitigated against leak, reducing both the leak rate and the likelihood of unplanned reoperations. Faecal diversion should be considered when ≥3 risk factors are present.Copyright © 2019 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Ileostomy creation is associated with postoperative dehydration and readmission; however, the effect on renal function is unknown. Our goal was to characterize the impact of ileostomy creation on acute and chronic renal function.A retrospective cohort study with patients undergoing colorectal cancer surgery at a tertiary referral institution (2005-2011). The relationship between ileostomy creation and acute kidney injury (AKI)-related readmission, severe chronic kidney disease (CKD) at 12 mo (glomerular filtration rate <30 mL/min/1.73 m), and onset of severe CKD over time was evaluated using multivariable logistic and Cox regression and adjusted using propensity score stratification.Among 619 patients, 84 (13%) had ileostomy. AKI-related readmission and severe CKD at 12 mo were more common among ileostomy patients (17% versus 2%, P < 0.01 and 13.3% versus 5%, P = 0.02, respectively). After propensity score adjustment, ileostomy was a significant predictor of AKI-related readmissions (odds ratio: 10.3; 95% confidence interval [CI], 3.9-27.2), severe CKD at 12 mo (odds ratio: 4.1; 95% CI, 1.4-11.9), and onset of severe CKD over time (hazard ratio: 4.2; 95% CI, 2.3-6.6).Ileostomy creation is associated with increased risk of AKI-related readmissions and development of severe CKD. Future studies must focus on strategies to minimize kidney injury when ileostomy is a necessary component of colorectal cancer surgery and revisiting current indications for ileostomy creation.Copyright © 2016 Elsevier Inc. All rights reserved.

Patients with double temporary enterostomy may suffer from intestinal failure (IF). Parenteral nutrition (PN) is the gold standard treatment until surgical reestablishment of intestinal continuity. Chyme reinfusion (CR) is a technique consisting in an extracorporeal circulation of the chyme. The aims were to determine: i) whether CR could restore intestinal absorption, decrease PN needs, improve nutritional status and plasma liver tests; ii) the feasibility of home CR.From the 232 patients IF consecutively referred for CR from 2000 to 2014, the 212 patients with IF, technical feasibility of CR, and effectively treated by CR, were included. Were collected prospectively before and during CR: daily stomal and fecal outputs, coefficients of nitrogen (CNDA) and fat (CFDA) digestive absorption, weight loss, body mass index (BMI), Nutritional Risk Index (NRI), plasma albumin, citrulline, and liver tests.183 patients had temporary double enterostomy and 29 exposed enterocutaneous fistulas. CR reduced the intestinal output (2444 ± 933 vs 370 ± 457 ml/day, P < 0.001), improved CNDA (46 ± 16 vs 80 ± 14%, P < 0.001) and CFDA (48 ± 25 vs 86 ± 11%, P < 0.001), and normalized plasma citrulline concentration (17.6 ± 8.4 vs 30.3 ± 11.8 μmol/l, P < 0.001). PN was stopped in 126/139 (91%) patients within 2 ± 8 d. Nutritional status improved (P < 0.001): weight (+4.6 ± 8.6%), BMI (+3.8 ± 7.7%), plasma albumin (+6.2 ± 6.1 g/l), and NRI (+10.9 ± 9.5). The proportion of patients with plasma liver tests abnormalities decreased (88 vs 51%, P < 0.01). Home CR was feasible without any serious complications in selected patients.CR corrected the intestinal failure by restoring intestinal absorption, allowing PN weaning in 91% of patients. CR contributes to improve nutritional status and to reduce plasma liver tests abnormalities, and is feasible at home.Copyright © 2016 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Duodenal Crohn's disease requiring surgery has traditionally been managed with a bypass procedure. We compared our experience with duodenal strictureplasty with this traditional approach.Records of patients operated on for duodenal Crohn's disease since 1980 were retrospectively reviewed. Patients having strictureplasty or bypass were compared with regard to demographics, indications, complications, and outcome.Since 1980, 34 patients were operated on for duodenal Crohn's disease. Mean age was 38.9 (range, 16-68) years, and 20 of 34 patients were females, with no significant differences between operative groups. Obstruction was the presenting symptom in 33 of 34 patients, and all had strictures. The basis for diagnosis of duodenal Crohn's disease was macroscopic appearance and the presence of Crohn's elsewhere in 29 of 34 patients, with only 5 of 34 having either duodenal or contiguous antral granulomas. Thirty-seven strictures were present in the 34 patients; 24 were in the proximal duodenum (8 strictureplasty, 16 bypass), 9 were in the midduodenum (4 strictureplasty, 5 bypass), and 4 were in the distal duodenum (3 strictureplasty, 1 bypass). Bypass was performed in 21 patients, with two operative complications, and at a mean follow-up of 8 years, 1 of 21 patients required reoperation for recurrent disease. Strictureplasty was performed in 13 patients, with two operative complication, and at a mean follow-up of 3.6 years, 1 patient required reoperation for recurrence also. Vagotomy was performed in 16 of 21 bypasses and 7 of 13 strictureplasties.Although follow-up is shorter, strictureplasty is a safe and effective operation for duodenal Crohn's disease and should be considered when feasible.

Surgical management of colonic Crohn's disease (CD) is still unclear because different procedures can be adopted. The choice of operation is dependent on the involvement of colonic disease but the advantages and disadvantages of the extent of resection are still debated.The aim of the present study was to evaluate the differences in short-term and long-term outcomes of adult patients with colonic CD who underwent either subtotal colectomy and ileorectal anastomosis (STC) or segmental colectomy (SC) or total proctocolectomy and end ileostomy (TPC). Studies published between 1984 and 2012 including comparisons of STC vs SC and of STC vs TPC were selected. The study end-points were overall and surgical recurrence, postoperative morbidity and incidence of permanent stoma. Fixed effect models were used to evaluate the study outcomes.Eleven studies, consisting of a total of 1436 patients (510 STC, 500 SC and 426 TPC), were included. Analysis of the data showed no significant difference between STC and SC in terms of overall and surgical recurrence of CD. In contrast, STC showed a higher risk of overall and surgical recurrence of CD than TPC (OR 3.53, 95% CI 2.45-5.10, P < 0.0001; OR 3.52, 95% CI 2.27-5.44, P < 0.0001, respectively). SC had a higher risk of postoperative complications compared to STC, and STC had a lower risk of complications than TPC (OR 2.84, 95% CI 1.16-6.96, P < 0.02; OR 0.19, 95% CI 0.09-0.38, P < 0.0001, respectively). SC resulted in a lower risk of permanent stoma than STC (OR 0.52, 95% CI 0.35-0.77).All three procedures were equally effective as treatment options for colonic CD and the choice of operation remains intrinsically dependent on the extent of colonic disease. However, patients in the TPC group showed a lower recurrence risk than those in the STC group. Moreover, SC had a higher risk of postoperative complications but a lower risk of permanent stoma. These data should be taken into account when deciding surgical strategies and when informing patients about postoperative risks.Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.

The extent of resection in colonic Crohn’s disease [cCD] is still a topic of debate, depending on the number of locations, the risk of recurrence and permanent stoma, and the role of medical therapy.

Previous studies on recurrence and reoperation after colectomy in Crohn's colitis have been based on heterogeneous groups of patients, and divergent findings may be explained by referral biases and small numbers of patients. The aim of this study was to account for recurrence rates, present risk factors for recurrence after primary colectomy, and account for the ultimate risk of having a stoma after colectomy with ileorectal anastomosis in patients with Crohn's colitis.Data on the primary resection, postoperative recurrence, influence of concomitant risk factors, frequency of stoma operations and proctectomy were evaluated retrospectively using multivariate analysis in a population-based cohort of 833 patients with Crohn's colitis.The cumulative 10-year risk of a symptomatic recurrence was 58 percent (95 percent confidence interval, 53-63 percent) and 47 percent (95 percent confidence interval, 42-52 percent), respectively, after colectomy with ileorectal anastomosis and segmental colonic resection. In colectomy with ileostomy, lower rates were found with respectively 24 percent (95 percent confidence interval, 18-30 percent) and 37 percent (95 percent confidence interval, 32-43 percent) after subtotal colectomy and proctocolectomy with ileostomy. The multivariate analysis showed that perianal disease, ileorectal anastomosis, and segmental resection were independent risk factors for postoperative recurrence. In 76 percent of patients with ileorectal anastomosis, a stoma-free function could be retained during a median follow-up of 12.5 years.Colectomy with ileorectal anastomosis or segmental resection is a feasible option in the surgical treatment of Crohn's colitis, although anastomoses, in addition to perianal disease, carry an increased risk of recurrent disease.

Subtotal or total colectomy or proctocolectomy with permanent ileostomy (TC‐PI) may be a treatment option for medically refractory colonic Crohn's disease (CD).

Debate exists on whether ileal pouch anal anastomosis [IPAA] can be safely offered to patients diagnosed with Crohn's disease [CD]. Our aim was to assess the outcome of IPAA for CD vs ulcerative colitis [UC].We used a PRISMA/MOOSE-compliant meta-analysis. Studies published between 1993 and 2018 were retrieved. Primary end points included complications. Secondary endpoints included functional outcome. The time of CD diagnosis was considered [intentional vs incidental IPAA].Eleven studies comprising 6770 patients [CD = 352, UC = 6418] were included, with 44-120 months of follow-up. Pouch fistulae were more common in CD (CD vs UC; odds ratio (OR) 6.08; p = 0.0003, GRADE+++), as were strictures [OR 1.82; p = 0.02, GRADE+++] and failure [OR 5.27; p < 0.0001, GRADE++++]. Compared with UC, postoperative CD diagnosis was associated with a much higher risk of fistulae [OR 6.23; p = 0.006, GRADE+++] and failure [OR 8.53; p < 0.0001, GRADE++++] than intentional IPAA in CD [fistula: OR 4.17; p = 0.04, GRADE+++; failure: OR 2.48; p = 0.009, GRADE++++]. Age at surgery was positively associated with failure in CD [p = 0.007]. Obstruction was more common after intentional IPAA for CD. The risk of pouchitis did not differ between CD and UC [OR 1.07, p = 0.76, GRADE+++]. CD patients were at a higher risk of seepage [OR 2.27; p = 0.010, GRADE++].Patients with CD have 5-fold higher risk of failure, and a 2-fold risk of strictures after IPAA compared with UC. The risk is much higher if diagnosis is performed after IPAA. Function in those who retain the pouch seemed similar to that of patients with UC. CD does not increase the risk of pouchitis. IPAA could be offered to a selected population of CD patients after proper preoperative counselling.[PROSPERO registry 116811].Copyright © 2019 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Ileal pouch anal anastomosis (IPAA) is the treatment of choice for chronic, medically refractory mucosal ulcerative colitis, indeterminate colitis, familial adenomatous polyposis (FAP), and a select group of patients with Crohn's disease.: We report outcomes, complications, and quality of life (QOL) in a cohort of 3707 patients treated at our institution from January 1984 to March 2010.Data were collected from a prospectively maintained database and chart review of 3707 consecutive primary IPAA cases. Patient demographics, postoperative complications, functional outcomes, and QOL data were available. Follow-up consisted of clinical examination with assessment of pouch function and QOL.A total of 3707 patients underwent primary pouch and 328 underwent redo pouch surgery. Postoperative histopathological diagnoses were mucosal ulcerative colitis (n = 2953, 79.7%), indeterminate colitis (n = 63, 1.7%), FAP (n = 223, 6%), Crohn's disease (n = 150, 4%), cancer/dysplasia (n = 97, 2.6%), and others (n = 221, 6.0%). Early perioperative complications were encountered in 33.5% of patients with a mortality rate of 0.1%. Excluding pouchitis, late complications were experienced by 29.1% of patients. Of those patients who had IPAA at our institution, pouch failure occurred in 197 patients (5.3%). During a median follow-up of 84 months, 119 patients (3.2%) required excision of the pouch, 32 (0.8%) had a nonfunctioning pouch, and 46 patients (1.2%) had redo IPAA. Functional outcomes and QOL were good or excellent in 95% of patients and similar in each histopathological subgroup.IPAA is an excellent option for patients with MUC, IC, FAP, and select patients with Crohn's disease.

Crohn's disease recurs in the majority of patients after intestinal resection.

Most patients with Crohn's disease (CD) eventually require an intestinal resection. However, CD frequently recurs after resection. We performed a randomized trial to compare the ability of infliximab vs placebo to prevent CD recurrence.We evaluated the efficacy of infliximab in preventing postoperative recurrence of CD in 297 patients at 104 sites worldwide from November 2010 through May 2012. All study patients had undergone ileocolonic resection within 45 days before randomization. Patients were randomly assigned (1:1) to groups given infliximab (5 mg/kg) or placebo every 8 weeks for 200 weeks. The primary end point was clinical recurrence, defined as a composite outcome consisting of a CD Activity Index score >200 and a ≥70-point increase from baseline, and endoscopic recurrence (Rutgeerts score ≥i2, determined by a central reader) or development of a new or re-draining fistula or abscess, before or at week 76. Endoscopic recurrence was a major secondary end point.A smaller proportion of patients in the infliximab group had a clinical recurrence before or at week 76 compared with the placebo group, but this difference was not statistically significant (12.9% vs 20.0%; absolute risk reduction [ARR] with infliximab, 7.1%; 95% confidence interval: -1.3% to 15.5%; P =.097). A significantly smaller proportion of patients in the infliximab group had endoscopic recurrence compared with the placebo group (30.6% vs 60.0%; ARR with infliximab, 29.4%; 95% confidence interval: 18.6% to 40.2%; P <.001). Additionally, a significantly smaller proportion of patients in the infliximab group had endoscopic recurrence based only on Rutgeerts scores ≥i2 (22.4% vs 51.3%; ARR with infliximab, 28.9%; 95% confidence interval: 18.4% to 39.4%; P <.001). Patients previously treated with anti-tumor necrosis factor agents or those with more than 1 resection were at greater risk for clinical recurrence. The safety profile of infliximab was similar to that from previous reports.Infliximab is not superior to placebo in preventing clinical recurrence after CD-related resection. However, infliximab does reduce endoscopic recurrence. ClinicalTrials.gov ID NCT01190839.Copyright © 2016 AGA Institute. Published by Elsevier Inc. All rights reserved.

Assessment of the efficacy of therapeutic approaches to anal lesions of Crohn's disease is frustrated by the lack of precise definition of its various manifestations. A classification that is clinical and based on anatomic and pathologic aspects is presented; it has been derived from a 20-year prospective study of anal Crohn's disease in Cardiff. Conceptually, the classification is analogous to the TNM system for cancer. The main classification (U.F.S.) defines the presence of Ulceration, Fistula/abscess, and Stricture, qualified by numeric values reflecting severity (0 = not present, 1 = limited clinical impact, and 2 = severe). A subsidiary classification (A.P.D.) defines Associated conditions, Proximal intestinal involvement, and Disease activity. In addition, the classification may be used in a detailed form for research or comparative purposes or in a simple form defining only the dominant lesions for routine clinical use. General use of the classification would make it possible to compare in detail incidence, management, and results of treatment in different centers.

Troublesome perianal disease occurs in approximately 35% of patients with Crohn's disease, yet conventional disease activity indices do not reflect the severity of this feature. To assess the degree of impairment and response to therapy, we identified five simple elements and graded each on a 5-point Likert scale in 37 patients at 124 visits. At each visit a Crohn's Disease (CDAI) or Simple Activity Index (HBDAI), Perianal Disease Activity Index (PDAI), and treatment were recorded. The PDAI was validated against physician (MDGA) and patient (PGA) global assessments, and treatment was prescribed for the perianal disease. Measurement error was evaluated in 19 patients who were clinically stable at two consecutive visits. The ability of the PDAI to detect important clinical change was tested in 20 subjects exhibiting a change on PGA at consecutive visits. There were strong correlations between PDAI, MDGA, and PGA scores at all visits (R = 0.66-0.72; p < 0.001), whereas the CDAI and HBDAI correlated poorly with PDAI (R < 0.23). Physicians prescribed more aggressive therapy for higher PDAI scores (r = 0.53). Mean PDAI scores between visits in clinically stable subjects were not significantly different [5.58 +/- 2.79 (initial); 5.42 +/- 2.55 (follow-up); p = 0.63]. PDAI significantly improved between visits when the perianal disease had improved (PDAI score difference 3.05 +/- 2.96; P =.0002). We conclude that the PDAI is simple and clinically useful for patient management. It should now be assessed in a clinical trial.

There is no validated magnetic resonance imaging (MRI) index for assessment of perianal fistulas in patients with Crohn's disease (CD). We developed and internally validated a new instrument.We used paired baseline and week-24 MRI scans from 160 participants in a randomized placebo-controlled trial of stem cell therapy for patients with perianal fistulizing CD. Four radiologists scored disease activity using index items identified during previous studies and exploratory items. Reliability was assessed using intraclass correlation coefficients. We developed an index using backward elimination linear regression analysis, in which potential independent variables were items having intraclass correlation coefficients of at least 0.4 and the dependent variable was perianal fistulizing disease activity, measured on a 100-mm visual analogue scale. The final model was internally validated using the.632 bootstrap method to correct model optimism and quantify calibration accuracy. We evaluated responsiveness of the index by assessing longitudinal validity and estimating standardized effect sizes.We developed the magnetic resonance novel index for fistula imaging in CD (MAGNIFI-CD) using 6 items. The optimism-corrected R of the model was 0.71, which was comparable to R for the original sample (0.74). The calibration slope for the model was 0.98. Compared with the original and modified versions of the Van Assche Index, the MAGNIFI-CD had improved operating characteristics. Estimates of intraclass correlation coefficients for MAGNIFI-CD, the modified Van Assche Index, and Van Assche Index were 0.85 (95% confidence interval [CI], 0.77-0.90), 0.81 (95% CI, 0.74-0.86), and 0.81 (95% CI, 0.71-0.86) for intra-rater reliability, and 0.74 (95% CI, 0.63-0.80), 0.67 (95% CI, 0.55-0.75) and 0.68 (95% CI, 0.56-0.77) for inter-rater reliability. Corresponding standardized effect size estimates were 1.02 (95% CI, 0.65-1.39), 0.84 (95% CI, 0.48-1.21), and 0.68 (95% CI, 0.33-1.03).We developed an index called the MAGNIFI-CD, which is based on 6 items. It assesses MRI data and determines perianal fistulizing CD activity with improved operating characteristics compared to previous indices. This index may be used as an outcome measure in clinical trials comparing treatment effects in patients with perianal fistulizing CD. Although the performance of the MAGNIFI-CD indicates its stability and reasonable external validity, external validation is needed.Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.

Vulval Crohn's disease (VCD) is a rare extra‐intestinal cutaneous manifestation of Crohn's disease. VCD is often unrecognized and misdiagnosed and can be difficult to treat. The aim of the study was to describe the clinical presentation, associated features, and response to treatment modalities in patients with VCD.

Surgical treatment of hemorrhoidal disease (HD) in inflammatory bowel disease (IBD) has been considered to be potentially harmful, but the evidence for this is poor. Therefore, a systematic review of the literature was undertaken to reappraise the safety and effectiveness of surgical treatments in this special circumstance. A MEDLINE, Web of Science, Scopus, and Cochrane Library search was performed to retrieve studies reporting the outcomes of surgical treatment of HD in patients with Crohn’s disease (CD) and ulcerative colitis (UC). From a total of 2072 citations, 10 retrospective studies including 222 (range, 2–70) patients were identified. Of these, 119 (54%) had CD and 103 (46%) UC. Mean age was between 41 and 49 years (range 14–77). Most studies lacked information on the interval between surgery and the onset of complications. Operative treatments included open or closed hemorrhoidectomy (n = 156 patients (70%)), rubber band ligation (n = 39 (18%)), excision or incision of thrombosed hemorrhoid (n = 14 (6%)), and doppler-guided hemorrhoidal artery ligation (DG-HAL, n = 13 (6%)). In total, 23 patients developed a complication (pooled prevalence, 9%; (95%CI, 3–16%)), with a more than two-fold higher rate in patients with CD compared to UC (11% (5–16%) vs. 5% (0–13%), respectively). Despite the low quality evidence, surgical management of HD in IBD and particularly in CD patients who have failed nonoperative therapy should still be performed with caution and limited to inactive disease. Further studies should determine whether advantages in terms of safety and effectiveness with the use of non-excisional techniques (e.g., DG-HAL) can be obtained in this patient population.

Controversy in performing hemorrhoidectomy and anal skin tag excision in patients with IBD stems from dated reports of nonhealing wounds resulting in proctectomy.This study aimed to determine the safety of interventional management of hemorrhoids or anal skin tags in patients with Crohn's disease or ulcerative colitis.This study is a retrospective review of patient records from 2000 to 2017.The patient records were retrieved from a multistate health system.Adult patients with IBD undergoing interventional management of hemorrhoids or skin tags were included.The primary outcome measured was the long-term requirement of proctectomy.Ninety-seven patients (n = 49 Crohn's disease, 48 ulcerative colitis) underwent interventional management of hemorrhoids or anal skin tags (n =35 rubber band ligation, 27 anal skin tag excision, 21 hemorrhoidectomy, 14 excision/incision of thrombosed hemorrhoid). Thirty-day complications were observed in 5 patients (n = 4 urinary retention, 1 perianal abscess). Five patients with Crohn's disease eventually required proctectomy at a median of 7 years after skin tag excision (range, 6 months to 10 years), but none were secondary to impaired wound healing. Two patients with ulcerative colitis who had previously undergone IPAA were subsequently diagnosed with Crohn's disease of the pouch after skin tag excision. No other long-term complications were seen in patients with ulcerative colitis.The study's retrospective design does not allow identification of patients with IBD who underwent only medical management of their hemorrhoids. There is also selection bias in which patients were selected for interventional management of their disease.The requirement for proctectomy after hemorrhoidectomy/skin tag excision appears to be secondary to the natural disease course of perianal Crohn's disease rather than perianal intervention. Selective hemorrhoidectomy and skin tag excision in patients with well-controlled luminal disease should be considered. See Video Abstract at http://links.lww.com/DCR/B55. HEMORROIDECTOMÍA ASOCIADA A LA EXCISIÓN DE PLICOMAS EN CASOS DE ENFERMEDAD INFLAMATORIA INTESTINAL: ¿ANUNCIO DE FATALIDAD O SIMPLEMENTE EVOLUCIÓN NATURAL DE LA ENFERMEDAD?: Está controvertida la realización de una hemorroidectomía asociada a la excisión de plicomas ano-cutáneos en pacientes con enfermedad inflamatoria intestinal, así lo han demostrado informes detallados sobre la no cicatrisación de las heridas conllevando a una proctectomía.Determinar los margenes de seguridad en casos de tratamiento instrumental de hemorroides asociadas a la excisión de plicomas ano-cutáneos en pacientes portadores de colitis ulcerosa o enfermedad de Crohn.Revisión retrospectiva de historias clinicas de pacientes entre 2000 y 2017.Servicio Multiestatal de Salud.Adultos con enfermedad inflamatoria intestinal sometidos a tratamiento instrumental de hemorroides asociado a la excisión de plicomas ano-cutáneos.Requisitos a largo plazo para una proctectomía.Noventa y siete pacientes (49 con enfermedad de Crohn, 48 con colitis ulcerosa) se sometieron a un tratamiento instrumental de hemorroides asociada a la excisión de plicomas ano-cutáneos (35 ligadura con bandas elásticas, 27 excisión de plicomas ano-cutáneos, 21 hemorroidectomías, 14 excisiones / incisiones de hemorroides trombosadas) Se observaron complicaciones a los 30 días en cinco pacientes (4 con retención urinaria, 1 absceso perianal). Cinco pacientes con enfermedad de Crohn requirieron proctectomía en una media de 7 años después de la excisión de los plicomas ano-cutáneos (rango, 6 meses a 10 años), pero ninguno fue secundario a la mala cicatrización de la herida. Dos pacientes con colitis ulcerosa que previamente se habían sometido a una anastomosis colo-anal protegia por ilestomía fueron diagnosticados posteriormente con enfermedad de Crohn localizada en la ostomía después de la excisión de plicomas ano-cutáneos. No se observaron complicaciones a largo plazo en pacientes con colitis ulcerosa.El diseño retrospectivo del estudio no permite la identificación de pacientes con enfermedad inflamatoria intestinal que se sometieron únicamente al tratamiento médico de las hemorroides. También existe un sesgo de selección de pacientes escogidos para tratamiento instrumental de la enfermedad hemorroidaria.El requisito de proctectomía después de la hemorroidectomía / excisión de plicomas anocutáneos parece ser secundario al curso de la enfermedad natural de la enfermedad de Crohn perianal en el sitio de la intervención perianal. Se debe considerar la hemorroidectomía selectiva y la excisión de plicomas ano-cutáneos solo en pacientes con enfermedad endoluminal controlada. Vea el video del resumen en http://links.lww.com/DCR/B55.

This study relates our experience with local surgical management of perianal Crohn's disease.Of 1,735 patients with Crohn's disease seen between 1980 and 1990, records of 66 patients (3.8 percent) with symptomatic perianal Crohn's disease treated by local operations were retrospectively reviewed to study outcome of local surgical intervention.All patients had intestinal disease that was limited to the colon in 32 patients (48 percent), ileocolonic region in 22 patients (33 percent), and ileum in 12 patients (18 percent). Types of perianal disease encountered included perianal suppuration (57), anal fistula (47), anal fissure (21), anal stenosis (5), gluteal abscess (3), scrotal abscess (2), and anovaginal fistula (2). A total of 321 episodes of anal complications necessitated 256 local surgical interventions. Local anorectal operations performed included simple incision and drainage of abscess (57), fistulotomy (35), incision and drainage of complex anorectal abscesses and fistulas and insertion of seton (24), internal sphincterotomy (6), fissurectomy (1), and anal dilation (3). Of 24 patients with horseshoe abscesses and fistulas managed with insertion of a seton and 35 patients who underwent fistulotomy as a primary procedure or in conjunction with drainage of an abscess, none experienced fecal incontinence as a direct result of the operation. Thirteen patients required proctectomy to control perianal disease, and a similar number underwent total proctocolectomy for extensive intestinal disease. Forty patients (61 percent) continue to retain a functional anus.Patients with symptomatic low anal fistula involving minimum sphincter musculature can be treated safely with fistulotomy. In treatment of patients with horseshoe abscesses and high fistulas, aggressive local surgical intervention using a seton permits preservation of the sphincter and good postoperative function.

Fistula-in-ano is a common problem among patients with Crohn's disease and carries significant morbidity. We aimed to study the outcomes of surgical treatment of fistula-in-ano after fistulotomy or seton placement in patients with perianal fistulizing Crohn's disease.A retrospective observational study of 59 patients diagnosed with Crohn's disease, who were treated surgically for fistula-in-ano between 2010 and 2014 in our department. The assessment of disease complexity included a detailed physical examination, magnetic resonance imaging of the rectum, and examination under anesthesia. Outcomes for analysis included wound healing rate and postoperative incontinence.High transsphincteric fistula was found in 44% of the patients, while mid or low transsphincteric fistulas were found in 51%. Three women (5%) had a rectovaginal fistula. All patients with high transsphincteric fistulas were treated with loose seton placement. Patients with mid- or low-level transsphincteric fistula were offered either fistulotomy or seton placement based on the clinical evaluation. The mean follow-up duration was 1.6 ± 1.1 years. In terms of recurrence, one patient treated with seton placement presented with recurrence 6 months after seton removal and one patient with fistulotomy failed to achieve wound healing. Minor incontinence was found in six patients treated with fistulotomy and in three patients treated with seton placement; however, this difference was not significant (chi-square = 1.723, df = 1, Monte-Carlo: p = 0.273).Fistulotomy could achieve good results in terms of wound healing and incontinence in strictly selected patients with Crohn's disease suffering from low-lying transsphincteric fistulae. For more high-lying or complicated fistulae, seton placement is more appropriate. For high transsphincteric fistulae, the only option is placement of loose seton.

Recurrence rates and long-term functional outcome after surgical treatment of anal fistula in Crohn's disease were assessed.A consecutive series of patients was treated for Crohn's fistula in ano; those without proctitis or active sepsis underwent surgery. Sex, seton usage, infliximab, previous fistula surgery, history of segmental resection and smoking were examined as risk factors for recurrence. Continence was assessed by Vaizey scale and a colorectal Functional outcome questionnaire. Results were compared with institutional data for cryptoglandular fistulas.Sixty-one patients were included, with a median follow-up of 79 (range 13-140) months. Twenty-four patients were treated with a seton, 28 by fistulotomy and nine by mucosal advancement. For low fistulas, fistulotomy was used more frequently than the seton, whereas seton drainage was used for most higher fistulas. Recurrence occurred in five of 28 and five of nine patients after fistulotomy and advancement respectively. Soiling was reported by half of the patients treated by seton versus two-thirds and three-quarters of those treated by fistulotomy and advancement respectively. Functional outcomes were worse for all patient groups than for cryptoglandular fistulas. No risk factor was significant.Surgical outcome for high or complex Crohn's fistula in ano remains disappointing, and recurrence is unpredictable.(c) 2009 British Journal of Surgery Society Ltd.

To examine the use of surgical procedures for Crohn's disease since the introduction of infliximab.Prior studies have shown that the overall rate of surgery for Crohn's disease has not changed significantly since the introduction of infliximab, an immunomodulator considered particularly effective in treating Crohn's fistulas. How infliximab has affected individual rates of specific types of procedures, particularly surgery for intestinal fistulas, is unknown.We used the Nationwide Inpatient Sample to identify all hospital admissions for Crohn's disease for each year from 1993 through 2004. Cases of Crohn's disease and relevant surgical interventions were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Using US Census data to establish population denominators, trends in population-based rates of use of these procedures were examined over time. Trends were tested for significance with Spearman rank correlation tests.From 1993 to 2004, there was no statistically significant change in population-based rates of small bowel and right colon resection, while rates of left colon resection, other colon resection, and rectal resection declined moderately. However, rates of surgical repair of fistulas of the small intestine, the most commonly performed fistula operation, increased by 60%, from 1.5 per 1,000,000 in 1993 to 2.4 per 1,000,000 in 2004 (P = 0.04).During the period of adoption of infliximab as a novel treatment for Crohn's disease, overall rates of bowel resections have either remained relatively stable or decreased moderately, while rates of small bowel fistula repair have increased significantly. These findings call into question the effectiveness of infliximab in preventing the need for surgery for Crohn's disease at the population level.

Fistulating perianal Crohn’s disease represents a significant challenge to both clinicians and patients. This survey set out to describe current practice and variation in the medical management of this condition.

Recent studies have confirmed that combined surgery and anti-TNF therapy could improve outcomes in patients with perianal fistulising Crohn's disease (PFCD). However, the optimal timing for infliximab infusion after surgical intervention is uncertain. We aimed to determine the long-term efficacy of early initiation of infliximab following surgery among PFCD patients.We performed a retrospective cohort study of PFCD patients who received combined infliximab and surgical treatment between 2010 and 2018 at a tertiary referral hospital. Patients were grouped according to the time interval between surgery and infliximab infusion, with < 6 weeks into early infliximab induction group and > 6 weeks into delayed infliximab induction group. The primary outcome was to compare surgical re-intervention between early and delayed infliximab induction groups. The secondary outcomes were fistula healing and predictors associated with these outcomes of early infliximab induction approach.One hundred and seventeen patients were included (73 in early infliximab induction, 44 in delayed infliximab induction). The median interval between surgery and infliximab initiation was 9.0 (IQR 5.5-17.0) days in early infliximab induction group and 188.0 (IQR 102.25-455.75) days in delayed infliximab induction group. After followed-up for a median of 36 months, 61.6% of patients in early infliximab induction group and 65.9% in delayed infliximab induction group attained fistula healing (p = 0.643). The cumulative re-intervention rate was 23%, 32%, 34% in early infliximab induction group and 16%, 25%, 25% in delayed infliximab induction group, at 1, 2, and 3 years respectively (p = 0.235). Presence of abscess at baseline (HR = 5.283; 95% CI, 1.61-17.335; p = 0.006) and infliximab maintenance therapy > 3 infusions (HR = 3.691; 95% CI, 1.233-11.051; p = 0.02) were associated with re-intervention in early infliximab induction group. Presence of abscess at baseline also negatively influenced fistula healing (HR = 3.429, 95% CI, 1.216-9.668; p = 0.02).Although no clear benefit was shown compared with delayed infliximab induction group, early initiation of infliximab after surgery could achieve promising results for PFCD patients. Before infliximab infusion, durable drainage is required for patients with concomitant abscess or prolonged infliximab maintenance therapy.© 2022. The Author(s).

Perianal fistulas occur in approximately 30% of patients with Crohn's disease (CD). Infliximab, a chimeric monoclonal antibody targeting human tumor necrosis factor alpha (TNF), is approved for the treatment of fistulizing CD. Although the initial response to infliximab is dramatic, the median duration of fistula closure is approximately 3 months, and repeated infusions are often required. An exam under anesthesia (EUA) by a surgeon allows for complete inspection of the fistula as well as incision and drainage of an abscess and placement of a seton. Our aim was to compare the rate of perianal fistula healing, relapse rate, and time to relapse in patients with fistulizing CD treated with infliximab alone or as an adjunct to surgical EUA with seton placement. Thirty-two consecutive patients with perianal fistulizing CD who completed at least 3 infusions with infliximab (5 mg/kg at 0, 2, 6 weeks) between October 1999 and October 2001 were analyzed. All patients had at least 3 months of follow-up after the third dose of infliximab. Response was defined as complete closure and cessation of drainage from the fistula. Patients with CD and perianal fistulas who had an EUA prior to infliximab infusions had a better initial response (100% vs. 82.6%, p = 0.014), lower recurrence rate (44% vs. 79%, p = 0.001), and longer time to recurrence (13.5 months vs. 3.6 months, p = 0.0001) compared with patients receiving infliximab alone. In conclusion, patients with fistulizing CD treated with infliximab are more likely to maintain fistula closure if treatment is preceded by EUA and seton placement.

The introduction of anti-tumour necrosis factor (anti-TNF; infliximab and adalimumab) has changed the management of Crohn's perianal fistula from almost exclusively surgical treatment to one with a much larger emphasis on medical therapy. The aim of this systematic review was to provide an overview of the success rates of setons and anti-TNF for Crohn's perianal fistula.Studies evaluating the effect of setons and anti-TNF on Crohn's perianal fistula were included. Studies assessing perianal fistula in children, rectovaginal and rectourinary fistulae were excluded. The primary end-point was the fistula closure rate. Partial closure and recurrence rates were secondary end-points.Ten studies on seton drainage were included (n = 305). Complete closure varied from 13.6% to 100% and recurrence from 0% to 83.3%. In 34 anti-TNF studies (n = 1449), complete closure varied from 16.7% and 93% (partial closure 8.0-91.2%) and recurrence from 8.0% to 40.9%. Four randomized controlled trials (n = 1028) comparing anti-TNF with placebo showed no significant difference in complete or partial closure in meta-analysis (risk difference 0.12, 95% CI -0.06 to 0.30 and 0.09, 95% CI -0.23 to 0.41, respectively). Subgroup analysis (n = 241) showed a significant advantage for complete fistula closure with anti-TNF in two trials with follow-up > 4 weeks (46% vs 13%, P = 0.003 and 30% vs 13%, P = 0.03). Of four included cohort studies, two revealed a significant difference in response in favour of combined treatment (P = 0.001 and P = 0.014).Closure and recurrence rates after seton drainage as well as anti-TNF vary widely. Despite a large number of studies, no conclusions can be drawn regarding the preferred strategy. However, combination therapy with (temporary) seton drainage, immunomodulators and anti-TNF may be beneficial in achieving perianal fistula closure.Colorectal Disease © 2016 The Association of Coloproctology of Great Britain and Ireland.

Treatment paradigms for Crohn′s disease with perianal fistulae (CD‐pAF) are evolving.

The management of perianal Crohn's fistulas represents a significant challenge. A combination of medical and surgical therapy, guided by radiology, is often required.

The use of cutting seton (CS) for the management of cryptoglandular fistula-in-ano has remained controversial because of reports of fecal incontinence, postoperative pain, and extended healing time. The aim of this review was to provide the first synthesis of studies investigating the use of CS for the treatment of cryptoglandular fistula-in-ano.MEDLINE, Embase, and CENTRAL were searched up to October 2022. Randomized controlled trials and observational studies comparing CS with alternative interventions were included, along with single-arm studies evaluating CS alone. The primary outcome was fistula-in-ano recurrence, and secondary outcomes included incontinence, healing time, proportion with complete healing, and postoperative pain. Inverse variance random-effects meta-analyses were used to pool effect estimates.After screening 661 citations, 29 studies were included. Overall, 1513 patients undergoing CS (18.8% female, mean age: 43.1 years) were included. Patients with CS had a 6% (95% CI: 3-12%) risk of recurrence and a 16% (95% CI: 5-38%) risk of incontinence at 6 months. CS patients had an average healing time of 14.6 weeks (95% CI: 10-19 weeks) with 73% (95% CI: 48-89%) of patients achieving complete healing at 6 months postoperatively. There was no difference in recurrence between CS and fistulotomy, advancement flap, two-stage seton fistulotomy, or draining seton.Overall, this analysis shows that CS has comparable recurrence and incontinence rates to other modalities. However, this may be at the expense of more postoperative pain and extended healing time. Further comparative studies between CS and other modalities are warranted.© 2023. Springer Nature Switzerland AG.

Fecal incontinence (FI) is a common complaint that greatly affects the quality of life of patients with Crohn's disease (CD) and is associated with the clinical characteristics of CD. We aimed to identify risk factors related to FI and construct a risk prediction model for FI in patients with CD.This retrospective study included 600 Chinese patients with CD from 4 IBD centers between June 2016 and October 2021. The patients were assigned to the training (n = 480) and testing cohorts (n = 120). Two nomograms were developed based on the logistic regression and Cox regression models to predict the risk factors for FI in patients with CD. The discriminatory ability and accuracy of the nomograms were evaluated using the receiver operating characteristic (ROC) curves and the area under the ROC curves (AUCs). Additionally, the Kaplan-Meier survival curve was also used further to validate the clinical efficacy of the Cox regression model.The overall prevalence of FI was 22.3% (n = 134 of 600). In the logistic regression model, age at diagnosis (odds ratio [OR], 1.032; P = .033), penetrating behavior of disease (OR, 3.529; P = .008) and Perianal Disease Activity Index score >4 (OR, 3.068; P < .001) were independent risk factors for FI. In the Cox regression model, age at diagnosis (hazard ratio [HR], 1.027; P = .018), Montreal P classification (HR, 2.608; P = .011), and Perianal Disease Activity Index score >4 (HR, 2.190; P = .001) were independent predictors of the prevalence of FI over time. Two nomograms were developed to facilitate risk score calculation, and they showed good discrimination ability according to AUCs.In this study, we identified 4 risk factors related to the prevalence of FI and developed 2 models to effectively predict the risk scores of FI in CD patients, helping to delay the course of FI and improve the prognosis with timely intervention.© The Author(s) 2024. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Objectives of surgical treatment for transsphincteric and complex anorectal fistulas are the successful elimination of current/recurrent disease and the preservation of sphincter function. The concept of endorectal advancement flaps is to preserve the sphincter by closing off the primary opening by means of a mobilized flap. We performed a systematic review of the literature to assess the role of this technique.A literature search on transanal rectal advancement flaps to treat cryptoglandular or Crohn fistula-in-ano was performed for the 30-year period between 1978 and 2008. Rectovaginal/rectourinary or cancer-related fistulas were excluded. Each study was examined for length of follow-up and the 2 major end points: success rate and incontinence rate.From 35 studies with 2065 patients, we identified 1654 patients undergoing endorectal advancement flaps for cryptoglandular or Crohn disease. Four hundred eleven subjects were excluded (319 rectovaginal/rectourinary fistulas; 92 other causes). The quality of the reports was limited (low-level evidence) with numerous structural and design flaws. Weighted success and incontinence rates were 80.8%/13.2% for cryptoglandular and 64%/9.4% for Crohn fistulas.Endorectal advancement flap is one tool, although not a perfect one, to treat complex anorectal fistulas of cryptoglandular or Crohn origin. Higher level evidence would be needed for comparison with other surgical techniques.

High perianal fistulas require sphincter-preserving surgery because of the risk of faecal incontinence. The ligation of the intersphincteric fistula tract (LIFT) procedure preserves anal sphincter function and is an alternative to the endorectal advancement flap (AF). The aim of this study was to evaluate outcomes of these procedures in patients with cryptoglandular and Crohn's perianal fistulas.A systematic literature search was performed using MEDLINE, Embase and the Cochrane Library. All RCTs, cohort studies and case series (more than 5 patients) describing one or both techniques were included. Main outcomes were overall success rate, recurrence and incontinence following either technique. A proportional meta-analysis was performed using a random-effects model.Some 30 studies comprising 1295 patients were included (AF, 797; LIFT, 498). For cryptoglandular fistula (1098 patients), there was no significant difference between AF and LIFT for weighted overall success (74·6 (95 per cent c.i. 65·6 to 83·7) 69·1 (53·9 to 84·3) per cent respectively) and recurrence (25·6 (4·7 to 46·4) 21·9 (14·8 to 29·0) per cent) rates. For Crohn's perianal fistula (64 patients), no significant differences were observed between AF and LIFT for overall success rate (61 (45 to 76) 53 per cent respectively), but data on recurrence were limited. Incontinence rates were significantly higher after AF compared with LIFT (7·8 (3·3 to 12·4) 1·6 (0·4 to 2·8) per cent).Overall success and recurrence rates were not significantly different between the AF and LIFT procedure, but continence was better preserved after LIFT.

Surgical management of anal fistulas in Crohn's disease (CD) is associated with high failure rates, and treatment options are limited due to ongoing proctitis, multiple tracts, and concern for incontinence and non-healing wounds. The aim of this study was to investigate the healing rate of ligation of the inters-sphincteric fistula tract (LIFT) for anal fistulas in Crohn's disease and identify prognostic factors for healing.This prospective analysis compared long-term healing rates of CD patients undergoing LIFT for anal fistulas. Consecutive patients with CD who underwent LIFT procedure at our institution, in the period from March 2012 to September 2019 were included. The main outcome was anal fistula healing rate.The study cohort of 46 patients (mean age of 34.2 ± 13.0 years, 18 (40%) males). After a mean follow-up time of 33 ± 28 months, fistula healing was seen in 30 (65%) patients. A total of 8 patients were noted to have inter-sphincteric recurrence and 8 patients had trans-sphincteric recurrence. Smoking at the time of surgery was significantly associated with LIFT failure (HR 3.18, 95% CI 1.18-8.61, p = 0.02). Other factors, such as age, sex, race, disease duration and location, type of fistula history of proctitis, preoperatively use of biologics or a seton, and previous repair attempts, did not appear to influence LIFT healing. Although not statistically significant, there was a trend toward increase in failure among patients with active proctitis at the time of surgery (HR 1.97, 95% CI 0.71-5.42, p = 0.19).Our increasing experience with LIFT for anal fistula in CD demonstrates a higher rate of healing (65%) than previously reported (48%). Smoking appears to negatively influence healing of LIFT in CD.© 2022. Springer Nature Switzerland AG.

The treatment of perianal fistulas in Crohn's disease remains challenging. Fibrin glue injection has previously shown short-term efficacy in a randomized controlled trial. No long-term data are available to assess the benefit of this treatment.This retrospective multicentre study included all patients with drained fistulas treated by at least one fibrin glue injection between January 2004 and June 2015 in three tertiary French centres. The primary end-point was the rate of complete clinical remission at 1 year after injection defined by the closure of all fistula tracts with no need for iterative anal surgery or for optimization of immunosuppressants and/or biologics.In all, 119 patients (median age 33 years, complex fistulas 65%, median previous anal surgery two, median Harvey Bradshaw score 3, immunosuppressants exposure 50%, anti-tumor necrosis factor exposure 60% with median time of administration of 1.1 year) were analysed with a median follow-up of 18.3 months. The complete clinical remission rate at 1 year was 45.4%. The primary end-point was achieved in 63% of the cases in the combination therapy group and 37% in other patients. The only predictor of complete clinical remission at 1 year was combination therapy at the time of injection (P = 0.01). The rate of early reintervention after glue injection was 2.5%. The cumulative incidence of iterative anal surgery and ostomy in the whole population was 54% and 5.6% respectively at 5 years.An adjunct of fibrin glue to conventional medical therapy may be an effective and safe treatment for perianal fistulas in patients with Crohn's disease.© 2020 The Association of Coloproctology of Great Britain and Ireland.

Anal fistula plug [AFP] is a bioabsorbable bioprosthesis used in ano-perineal fistula treatment. We aimed to assess efficacy and safety of AFP in fistulising ano-perineal Crohn's disease [FAP-CD].In a multicentre, open-label, randomised controlled trial we compared seton removal alone [control group] with AFP insertion [AFP group] in 106 Crohn's disease patients with non- or mildly active disease having at least one ano-perineal fistula tract drained for more than 1 month. Patients with abscess [collection ≥ 3mm on magnetic resonance imaging or recto-vaginal fistulas were excluded. Randomisation was stratified in simple or complex fistulas according to AGA classification. Primary end point was fistula closure at Week 12.In all, 54 patients were randomised to AFP group [control group 52]. Median fistula duration was 23 [10-53] months. Median Crohn's Disease Activity Index at baseline was 81 [45-135]. Fistula closure at Week 12 was achieved in 31.5% patients in the AFP group and in 23.1 % in the control group (relative risk [RR] stratified on AGA classification: 1.31; 95% confidence interval: 0.59-4.02; p = 0.19). No interaction in treatment effect with complexity stratum was found; 33.3% of patients with complex fistula and 30.8% of patients with simple fistula closed the tracts after AFP, as compared with 15.4% and 25.6% in controls, respectively [RR of success = 2.17 in complex fistula vs RR = 1.20 in simple fistula; p = 0.45]. Concerning safety, at Week 12, 17 patients developed at least one adverse event in the AFP group vs 8 in the controls [p = 0.07].AFP is not more effective than seton removal alone to achieve FAP-CD closure.Copyright © 2015 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Most patients with perianal fistulizing Crohn's disease (pfCD) present with complex types of perianal fistulas and need repetitive repair operations, resulting in a high risk of sphincter injury. Fistula-tract Laser Closure (FiLaC™) is a novel sphincter-saving technique that obliterates the fistula tract with a photothermal effect. The aim of the present systematic review and meta-analysis was to evaluate the efficacy and safety of FiLaC in pfCD.This study was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Electronic databases, including PubMed, Embase, Cochrane Library and Wanfang Data were searched for published articles from January 2000 to June 2021. The clinicaltrials.gov website was searched for completed or ongoing trials on pfCD and FiLaC™. The references of each article were also searched for eligible data. The main outcome was the primary healing rate of the FiLaC™ procedure. Additionally, fecal incontinence was analyzed as the secondary outcome to evaluate the safety of FiLaC™.Six studies met the eligibility criteria and were included in the final analysis. All studies were published within the past 6 years and came from European countries. There were 50 pfCD patients recruited, and 31 patients' fistulas were healed after FiLaC™. The pooled primary healing rate was 68% (95% CI 53.0-84.0%, I = 27%, p = 0.23). There was no major fecal incontinence after surgery.These data suggest that FiLaC™ may be an effective and safe procedure for pfCD patients. However, the evidence is poor and there is a need for more high-quality prospective controlled studies with long-term follow-up before this minimally invasive technique is recommended for surgical treatment of pfCD.© 2022. Springer Nature Switzerland AG.

Fistula-tract laser closure (FiLaC™) has shown promising outcomes in perianal fistulizing Crohn's disease (pfCD). However, most studies assessed a mixed cohort encompassing pfCD and cryptoglandular fistulas during a short follow-up period. This study aimed to evaluate the long-term treatment outcomes of FiLaC™ in patients with complex pfCD.Data from patients with complex pfCD who underwent FiLaC™ during deep remission of Crohn's disease between January 2019 and December 2020 were retrospectively analyzed. Patient demographics, surgery history, and medication strategy were registered before surgery. Follow-ups were scheduled at 1, 2, and 3 months after FiLaC™, and at 2-month intervals thereafter. The primary endpoint was clinic healing, while clinic remission/unhealed/recurrence were classified as unhealed. Additionally, adverse events and Wexner fecal incontinence score were documented.Forty-nine patients (40 men and 9 women) with a median age of 26.0 (19.0-35.5) years were included with a median follow-up of 50.0 (39.5-54.0) months. Of these, 31 (63.3%) patients achieved fistula healing, 3 (6.1%) experienced improvement, 3 (6.1%) remained unhealed, and 12 (24.5%) experienced recurrence. Montreal A category was lower in the healed group (P < 0.001). No major complications, such as bleeding or fecal or urinary incontinence, were observed, and pain was transient. The Wexner incontinence score decreased significantly at the last available follow-up, indicating an intact postoperative continence function (P = 0.014). PCDAI scores were significantly higher in the unhealed group (P = 0.041).FiLaC™ is an efficient and safe sphincter-saving procedure for patients with complex pfCD.© 2024. Springer Nature Switzerland AG.

A third of patients with Crohn's disease develop perianal fistulas. These are associated with a significant burden of symptoms and negative impact on quality of life. This study reports the use of video-assisted anal fistula treatment [VAAFT] as a means of symptom improvement; this is a minimally invasive technique to access fistula track, and diagnose/facilitate drainage of deep/complex secondary extensions with cauterization of excess inflammatory tissue.Consecutive patients with complex Crohn's fistula undergoing VAAFT for symptomatic Crohn's anal fistula were included. They were identified from a prospectively maintained database, which was interrogated from June 2015 to November 2017. Patients underwent diagnostic fistuloscopy and fulguration of tracts/secondary extensions. Setons were sited/replaced after the procedure to maintain postoperative drainage. The primary endpoint was completion of the 'Measure your medical outcome profile' [MYMOP2] quality of life [QoL] questionnaire at 6 weeks postoperatively. Secondary outcome measures were a decisional regret scale [DRS], postoperative complications and the 30-day re-operation rate.Twenty-five patients underwent the procedure during the study period. In total, 21/25 patients [84%] provided MYMOP2 QoL data demonstrating a statistically significant improvement in both pain and discharge scores. Eighty-one per cent of patients who completed the questionnaire agreed/strongly agreed that the procedure was the right decision and no patient regretted undergoing the procedure. There was one re-operation but otherwise no complications.This study demonstrates the feasibility, safety and importantly an improvement in patient-reported outcomes in a series of patients undergoing VAAFT for complex Crohn's anal fistula. VAAFT reduces the main symptoms [pain and discharge] in patients with complex refractory anal fistulas.Copyright © 2018 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Therapies for perianal fistulas in patients with Crohn's disease are often ineffective in producing long-term healing. We performed a randomized placebo-controlled trial to determine the long-term efficacy and safety of a single local administration of allogeneic expanded adipose-derived stem cells (Cx601) in patients with Crohn's disease and perianal fistulas.We performed a double-blind study at 49 hospitals in Europe and Israel, comprising 212 patients with Crohn's disease and treatment-refractory, draining, complex perianal fistulas. Patients were randomly assigned (1:1) to groups given a single local injection of 120 million Cx601 cells or placebo (control), in addition to the standard of care. Efficacy endpoints evaluated in the modified intention-to-treat population (randomly assigned, treated, and with 1 or more post-baseline efficacy assessment) at week 52 included combined remission (closure of all treated external openings draining at baseline with absence of collections >2 cm, confirmed by magnetic resonance imaging) and clinical remission (absence of draining fistulas).The study's primary endpoint, at week 24, was previously reported (combined remission in 51.5% of patients given Cx601 vs 35.6% of controls, for a difference of 15.8 percentage points; 97.5% confidence interval [CI] 0.5-31.2; P =.021). At week 52, a significantly greater proportion of patients given Cx601 achieved combined remission (56.3%) vs controls (38.6%) (a difference of 17.7 percentage points; 95% CI 4.2-31.2; P = .010), and clinical remission (59.2% vs 41.6% of controls, for a difference of 17.6 percentage points; 95% CI 4.1-31.1; P = .013). Safety was maintained throughout week 52; adverse events occurred in 76.7% of patients in the Cx601 group and 72.5% of patients in the control group.In a phase 3 trial of patients with Crohn's disease and treatment-refractory complex perianal fistulas, we found Cx601 to be safe and effective in closing external openings, compared with placebo, after 1 year. ClinicalTrials.gov no: NCT01541579.Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.

Darvadstrocel is an expanded allogeneic adipose-derived mesenchymal stem cell therapy for the treatment of complex perianal fistulas in patients with Crohn’s disease. Safety and efficacy outcomes from the clinical trial known as “Adipose derived mesenchymal stem cells for induction of remission in perianal fistulizing Crohn’s disease,” or ADMIRE-CD (NCT01541579), from up to 52 weeks posttreatment were previously reported. Here, the outcomes from an extended 104-week follow-up are reported.

Perianal fistulas may affect 15-50% of patients with Crohn's disease. Treatment is complex, requiring a multidisciplinary approach. Darvadstrocel (allogenic mesenchymal cells obtained from lipoaspirates) was approved in 2018 by the European and Spanish Agencies of Medicines and Medical Products as a treatment for fistulas in Crohn's disease. Recent European Crohn's and Colitis Organisation and Spanish Working Group on Crohn's Disease and Ulcerative Colitis guidelines state that darvadstrocel is effective with a favorable safety profile and a strong level of evidence (2).Presenting real-world effectiveness data for darvadstrocel in a Spanish population.Observational retrospective cohort study with prospective data gathering.Fourteen institutions.From November 2019-April 2022, all patients (73) treated with darvadstrocel in these institutions were included, fulfilling the following criteria: 1) complex fistula/s in a patient with Crohn's disease; 2) failure of conventional and antitumor necrosis factor treatment; 3) absence of collections >2 cm confirmed by pelvic MRI scan at the time of surgery.Darvadstrocel treatment.Clinical response (closure of ≥50% of external openings), complete clinical closure (100% of external openings) and radiological closure (no fluid collection >2 cm, no edema or inflammation) evaluated 6 months after treatment.Clinical response was observed in 63 patients (86.3%), complete clinical closure in 50 patients (68.5%) and radiological closure in 45 patients (69.2%). Combined clinical and radiological response was observed in 41 patients (63.1%). Not all clinically healed patients had radiological closure and vice versa. No serious adverse events were reported.Retrospective.Study results were consistent with those reported in previous clinical trials, real-world efficacy findings from the INSPIRE study (assessing darvadstrocel effectiveness in Europe, Israel, Switzerland, UK, and Japan) and previously published literature. Darvadstrocel was effective and demonstrated a favorable safety profile when used in normal clinical practice for treatment of fistulas in Crohn's disease. See Video Abstract.Copyright © The ASCRS 2024.

There has been a surge in clinical trials studying the safety and efficacy of mesenchymal stem cells for the treatment of perianal Crohn's disease.The purpose of this work was to systematically review the literature to determine safety and efficacy of mesenchymal stem cells for the treatment of refractory perianal Crohn's disease.Sources included PubMed, Cochrane Library Central Register of Controlled Trials, and Embase.Studies that reported safety and/or efficacy of mesenchymal stem cells for the treatment of perianal Crohn's disease were included. Two independent assessors reviewed eligible articles.The study intervention was delivery of mesenchymal stem cells to treat perianal Crohn's disease.Safety and efficacy of mesenchymal stem cells used to treat perianal Crohn's disease were measured.Eleven studies met the inclusion criteria and were included in the systematic review. Three trials with a comparison arm were included in the meta-analysis. There were no significant increases in adverse events (OR = 1.07 (95% CI, 0.61-1.89); p = 0.81) or serious adverse events (OR = 0.53 (95% CI, 0.28-0.98); p = 0.04) in patients treated with mesenchymal stem cells. Mesenchymal stem cells were associated with improved healing as compared with control subjects at primary end points of 6 to 24 weeks (OR = 3.06 (95% CI, 1.05-8.90); p = 0.04) and 24 to 52 weeks (OR = 2.37 (95% CI, 0.90-6.25); p = 0.08).The study was limited by its multiple centers and heterogeneity in the study inclusion criteria, mesenchymal stem cell origin, dose and frequency of delivery, use of scaffolding, and definition and time point of fistula healing.Although there have been only 3 trials conducted with control arms, existing data demonstrate improved efficacy and no increase in adverse or serious adverse events with mesenchymal stem cells as compared with control subjects for the treatment of perianal Crohn's disease.

Rectovaginal and enterovesical fistulae are difficult to treat in patients with Crohn's disease. Currently, there is no consensus regarding their appropriate management.The aim of the study was to review the literature on the medical management of rectovaginal and enterovesical fistulae in Crohn's disease and to assess their response to treatment.A literature search of MEDLINE, EMBASE, Science Citation Index Expanded, and Cochrane was performed.Twenty-three studies were identified, reporting on 137 rectovaginal and 44 enterovesical fistulae. The overall response rates of rectovaginal fistulae to medical therapy were: 38.3% complete response (fistula closure), 22.3% partial response, and 39.4% no response. For enterovesical fistulae the response rates to medical therapy were: 65.9% complete response, 20.5% partial response, and 13.6% no response. Specifically, response to anti-tumor necrosis factor therapy of 78 rectovaginal fistulae was: 41.0% complete response, 21.8% partial response, and 37.2% no response. Response of 14 enterovesical fistulae to anti-tumor necrosis factor therapy was: 57.1% complete response, 35.7% partial response, and 7.1% no response. The response to a combination of medical and surgical therapy in 43 rectovaginal fistulae was: 44.2% complete response, 20.9% partial response, and 34.9% no response.Medical therapy, alone or in combination with surgery, appears to benefit some patients with rectovaginal or enterovesical fistula. However, given the small size and low quality of the published studies, it is still difficult to draw conclusions regarding treatment. Larger, better quality studies are required to assess response to medical treatment and evaluate indications for surgery.

Crohn's disease (CD)-related rectovaginal fistulas (RVFs) and anovaginal fistulas (AVFs) are rare, debilitating conditions that present a substantial disease and treatment burden for women. This systematic literature review (SLR) assessed the burden of Crohn's-related RVF and AVF, summarizing evidence from observational studies and highlighting knowledge gaps.This SLR identified articles in PubMed and Embase that provide data and insight into the patient experience and disease burden of Crohn's-related RVF and AVF. Two trained reviewers used pre-specified eligibility criteria to identify studies for inclusion and evaluate risk of bias using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool for observational studies.Of the 582 records identified, 316 full-text articles were assessed, and 16 studies met a priori eligibility criteria and were included. Few epidemiology studies were identified, with one study estimating the prevalence of RVF to be 2.3% in females with Crohn's disease. Seven of 12 treatment pattern studies reported that patients had or required additional procedures before and/or after the intervention of interest, demonstrating a substantial treatment burden. Seven of 11 studies assessing clinical outcomes reported fistula healing rates between 50 and 75%, with varying estimates based on population and intervention.This SLR reports the high disease and treatment burden of Crohn's-related RVF and AVF and identifies multiple evidence gaps in this field. The literature lacks robust, generalizable data, and demonstrates a compelling need for substantial, novel research into these rare and debilitating sequelae of CD. Registration The PROSPERO registration number for the protocol for this systematic literature review is CRD42020177732.© 2022. The Author(s).

Rectovaginal fistula occurs in up to 10–20% of women with Crohn’s disease, significantly affecting their quality of life. We sought to determine outcomes of single and repeat operative interventions.

Forty-four patients seen between 1975 and 1985 with anorectal strictures complicating Crohn's disease have been reviewed to determine the natural history and outcome of surgical treatment. Proctitis was present in 98 per cent, and 93 per cent of patients had severe perianal disease. The site of strictures was rectal in 22, anal in 15 and anorectal in 11 (4 patients had a stricture at 2 sites). Initial treatment was by rectal excision alone in 6, dilatation in 33, and 5 needed no treatment at all. Single dilatation was effective in 15, 8 required two dilatations and in 10 repeated dilatation was necessary. Proctocolectomy was eventually required in 19 patients, 2 have a loop ileostomy and I has an ileostomy with a rectal stump in situ. Only 21 remain asymptomatic while 3 continue to need dilatation. Perineal wound healing was delayed in 9 of 19 patients having a proctocolectomy and in 3 the perineal wound has never healed.

The natural history of nonfistulising perianal Crohn's disease (PCD) remains unknown.

Current surgical options for the treatment of rectal stricture are either technically difficult or result in a high rate of recurrence. We describe the results of a simple and potentially effective technique of transanal stricturoplasty using the Heineke-Mikulicz principle.The medical records and a prospectively maintained database of patients with rectal stricture were searched. Those who underwent transanal stricturoplasty for an anorectal stricture from 2007 to 2013 were studied retrospectively. Morbidity, length of hospital stay and the rates of success and recurrence were recorded.Fifteen patients with a symptomatic rectal stricture who failed dilatation underwent transanal stricturoplasty. The types of stricture included strictures in Crohn's disease (n = 7) and anastomotic stricture after stapled ileoanal anastomosis for ulcerative colitis (n = 4), after stapled hemorrhoidopexy (n = 3) and after low anterior resection for rectal cancer (n =1). The median (range) distance of the stricture from the dentate line was 4 (0-6) cm. Recurrence of symptoms after anal dilatation occurred at a median of 3 (1-4) weeks. The median follow up after transanal stricturoplasty was 21 (6-88) months. Two patients had symptomatic recurrence at 12 months and both underwent a repeat transanal stricturoplasty, resulting in persistent patency of the strictured area at the time of the last follow up, 10 and 26 months, respectively, after repeat transanal stricturoplasty. The remaining 13 had a satisfactory result.Despite the retrospective nature of this report and the small sample size and short follow up, the results strongly suggest that transanal Heineke-Mikulicz-type stricturoplasty is a promising treatment for this important condition. This operation is easy to perform and may result in success.Colorectal Disease © 2015 The Association of Coloproctology of Great Britain and Ireland.

This article is the second in a series of two publications on the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of prior ECCO Guidelines.© The Author(s) 2024. Published by Oxford University Press on behalf of European Crohn’s and Colitis Organisation. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.

Temporary faecal diversion is sometimes used for management of refractory perianal Crohn's disease (CD) with variable success.

We evaluated short- and long-term outcomes of temporary faecal diversion [FD] for management of refractory Crohn’s disease [CD], focusing on outcomes in the biologic era.

Nonhealing perineal wounds have been reported to be common after proctectomy for Crohn’s disease (CD). We performed a systematic review and meta-analysis of perineal wound healing after proctectomy for CD and assessed the risk factors for nonhealing.

Despite the high incidence of involvement of the perianal region in Crohn's disease, excisional surgery seldom is required for perianal disease alone. Nine patients are presented who had severe perianal Crohn's disease, which eventually required abdominoperineal excision of the anorectum. In all nine patients, it was secondary manifestations of anal Crohn's disease that precipitated proctectomy, such as high fistulas, strictures, and rectovaginal fistulas. These secondary phenomena, especially fistulas caused by cavitating ulceration, become self-perpetuating by the mechanical effect of feces being forced into the tract. During the same period, 17 patients required rectal excision by abdominoperineal resection, where perianal disease was incidental to severe colorectal disease. There is a tendency for excessive delay before advising surgery for severe perianal disease. An attempt should be made to identify patients with a poor prognosis to avoid unnecessarily prolonged morbidity. Assessment of the exact nature of the anal lesion and assessment of Crohn's disease activity are important in making this decision.

Carcinoma associated with perianal fistula in Crohn's disease is a pending threat for patients. This study was aimed to improve understanding and facilitate development of diagnostic and therapeutic strategies.A retrospective case-control study was conducted at four German hospitals. The analysis included forty patients with proven malignancy associated with perianal Crohn's fistulas and forty randomly-selected controls with fistulizing perianal Crohn's disease. Differences between groups were analysed and multivariate calculations performed to describe risk factors for oncological outcomes.Histology revealed adenocarcinoma in 33/40 patients and squamous cell carcinoma in 7/40 patients. Compared to fistula patients without carcinoma, patients with malignancies associated to fistula had a diagnosis of Crohn's disease in younger age. Crohn's disease lasted longer in patients with malignancy (25.8 ± 9.0 vs. 19.6 ± 10.4; p=0.006).Fistula related findings differed significantly between both groups. Signs for complicated and severe fistulation including complex anatomy and chronic activity occurred significantly more often in patients with malignancy associated to fistula.Significant multivariate hazard ratios for overall mortality and progression-free survival were shown for histologic type of cancer, metastatic disease and R1 resection. Overall survival (OS) was 45.1±28.6 months and the 5-year survival rate was 65%.In patients with adenocarcinoma or squamous cell carcinoma associated with perianal fistula in Crohn's disease, fistula characteristics determine risk for malignancy. Early diagnosis influences outcomes, while treatment of chronic fistula activity may be key to preventing malignancy. Expert multimodal therapy is paramount for successful treatment of perianal fistula-associated malignancies.© The Author(s) 2021. Published by Oxford University Press on behalf of European Crohn’s and Colitis Organisation. All rights reserved. For permissions, please email: journals.permissions@oup.com.