Willem A. Bemelman,a Janindra Warusavitarne,b Gianluca M. Sampietro,c Zuzana Serclova,d Oded Zmora,e Gaetano Luglio,f Anthony de Buck van Overstraeten,g John P. Burke,h Christianne J. Buskens,a Francesco Colombo,c Jorge Amil Dias,i Rami Eliakim,j Tomás Elosua,k I. Ethem Gecim,l Sanja Kolacek,m Jaroslaw Kierkus,n Kaija-Leena Kolho,o Jérémie H. Lefevre,p Monica Millan,q Yves Panis,r Thomas Pinkney,s Richard K. Russell,t Chaya Shwaartz,u Carolynne Vaizey,b Nuha Yassin,v André D’Hooreg; on behalf of the European Crohn’s and Colitis Organisation [ECCO] and the European Society of Colo-Proctology [ESCP]

/pdf/ecco-escp-consensus-on-surgery-for-crohn-s-disease-4npeptdti8.pdf

ECCO-ESCP Consensus on Surgery for Crohn's Disease.

Objective The authors assess the effect of surgical margin width on recurrence rates after intestinal resection for Crohn's Disease (CD). Background The optimal width of margins when resecting CD of the small bowel is controversial. Most studies have been retrospective and have had conflicting results. Methods Patients undergoing ileocolic resection for CD (N = 152) were randomly assigned to two groups in which the proximal line of resection was 2 cm (limited resection) or 12 cm (extended resection) from the macroscopically involved area. Patients also were classified by whether the margin of resection was microscopically normal (category 1), contained nonspecific changes (category 2), were suggestive but not diagnostic for CD (category 3), or were diagnostic for CD (category 4). Recurrence was defined as reoperation for recurrent preanastomotic disease. Results Data were collected on 131 patients. Median follow-up time was 55.7 months. Disease recurred in 29 patients : 25% of patients in the limited resection group and 18% of patients in the extended resection group. In the 90 patients in category 1 with normal tissue, recurrence occurred in 16, whereas in the 41 patients with some degree of microscopic involvement, recurrence occurred in 13. Recurrence rates were 36% in category 2, 39% in category 3, and 21% in category 4. No group differences were statistically significant at the 0.01 level. Conclusion Recurrence of CD is unaffected by the width of the margin of resection from macroscopically involved bowel. Recurrence rates also do not increase when microscopic CD is present at the resection margins. Therefore, extensive resection margins are unnecessary.

Effect of resection margins on the recurrence of Crohn's disease in the small bowel. A randomized controlled trial.

This study was designed to review safety and efficacy of strictureplasty for Crohn’s disease. A literature search was performed to identify studies published between 1975 and 2005 that reported the outcome of strictureplasty. Systematic review was performed on the following subjects separately: 1) overall experience of strictureplasty; 2) postoperative complications; 3) postoperative recurrence and site of recurrence; 4) factors affecting postoperative complications and recurrence; 5) short-bowel syndrome; and 6) cancer risk. Meta-analysis of recurrence rate after strictureplasty was performed by using random-effect model and meta-regressive techniques. A total of 1,112 patients who underwent 3,259 strictureplasties (Heineke-Mikulicz, 81 percent; Finney, 10 percent; side-to-side isoperistaltic, 5 percent) were identified. The sites of strictureplasty were jejunum and/or ileum (94 percent), previous anastomosis (4 percent), duodenum (1 percent), and colon (1 percent). After jejunoileal strictureplasty, including ileocolonic strictureplasty, septic complications (leak/fistula/abscess) occurred in 4 percent of patients. Overall surgical recurrence was 23 percent (95 percent confidence interval, 17-0 percent). Using meta-regressive analysis, the five-year recurrence rate after strictureplasty was 28 percent. In 90 percent of patients, recurrence occurred at nonstrictureplasty sites, and the site-specific recurrence rate was 3 percent. Two patients developed adenocarcinoma at the site of previous jejunoileal strictureplasty. The experience of duodenal or colonic strictureplasty was limited. Strictureplasty is a safe and effective procedure for jejunoileal Crohn’s disease, including ileocolonic recurrence, and it has the advantage of protecting against further small bowel loss. However, the place for strictureplasty is less well defined in duodenal and colonic diseases.

Safety and efficacy of strictureplasty for Crohn's disease: a systematic review and meta-analysis.

/pdf/a-tale-of-two-diseases-the-history-of-inflammatory-bowel-fhhdrie2z1.pdf

A tale of two diseases: The history of inflammatory bowel disease

Chron’s Disease is a chronic inflammatory intestinal disease, first described at the beginning of the last century. The disease is characterized by the alternation of periods of flares and remissions influenced by a complex pathogenesis in which inflammation plays a key role. Crohn’s disease evolution is mediated by a complex alteration of the inflammatory response which is characterized by alterations of the innate immunity of the intestinal mucosa barrier together with a remodeling of the extracellular matrix through the expression of metalloproteins and increased adhesion molecules expression, such as MAcCAM-1. This reshaped microenvironment enhances leucocytes migration in the sites of inflammation, promoting a TH1 response, through the production of cytokines such as IL-12 and TNF-α. IL-12 itself and IL-23 have been targeted for the medical treatment of CD. Giving the limited success of medical therapies, the treatment of the disease is invariably surgical. This review will highlight the role of inflammation in CD and describe the surgical approaches for the prevention of the almost inevitable recurrence.

/pdf/pathophysiology-of-crohn-s-disease-inflammation-and-2utzwbon0x.pdf

Pathophysiology of Crohn's disease inflammation and recurrence.

Patients with extensive chronic Crohn's disease of the small bowel, who may have had repeated excisional surgery, sometimes develop intestinal obstruction due to the development of a stricture. Surgery is usually thought to be contraindicated since further resections would leave the patient with insufficient small intestine to maintain a normal state of nutrition. Nine such patients have been treated since 1979 by operations which have been designed simply to relieve the obstruction. After careful preparation with intravenous alimentation, clearing the intestine of its contents, and the use of prophylactic antibodies the strictures were treated with minimal excisions, enteroenterostomies, and 'strictureplasties' according to their length and the degree of inflammation. In spite of the apparent danger of carrying out the operations through active Crohn's inflammation there have been no fatalities or major complications and the long-term results have been good.

Minimal surgery for chronic obstruction in patients with extensive or universal Crohn's disease.

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Minimal surgery for chronic obstruction in patients with extensive or universal Crohn's disease.