Introduction

Side-to-side antiperistaltic ileo-colonic anastomosis (APICA) is wildly used technique in Crohn's disease (CD) patients. Its configuration makes the neo-terminal ileum intubation difficult, and might reduce rates of appropriate scoping, as required for assessment of disease relapse. The isoperistaltic ileo-colonic anastomosis (IPICA) may improve post-surgical endoscopic follow up of CD patients.

Aims & Methods

Our aim was to compare safety, efficacy, recurrence rates and feasibility of ileo-colonoscopy (IC) between the two anastomotic configurations.
​Data on all consecutive CD patients aged ≥18 years at a single tertiary center, who underwent ileo-colonic resection from 1/4/12 to 31/3/22, were collected retrospectively. Patients with anastomotic types other than APICA and IPICA and lack of IC within 18 months from surgery, were excluded.

Results

A total of 143 patients were included [82 males (57.3%), age 38.2±14.3 years, disease duration 10.1±9.5 years]. Twenty-six patients (18.5%) underwent IPICA and 117 patients (81.8%) APICA surgery. Patients did not differ in age, gender, BMI, smoking status, biologic treatment exposure and disease duration at time of surgery (p=NS). Duration of surgery was significantly longer for IPICA than APICA (295.4±70.2 min vs 249.3±60.6 min, p<0.001, respectively). Rates of laparoscopic, lap-to-open and open procedures differed (57.7%, 30.8% and 11.5% for IPICA vs. 40.2%, 13.7% and 46.2%, for APICA, respectively; p=0.003). Hospitalization duration and post-surgical complications (Clavien-Dindo classification) were comparable (p=NS). Fifteen patients were re-admitted with post-surgical complications within 90 days [1/26 (3.8%) in IPICA vs. 14/117 (12.0%) in APICA group, p=0.12]. At post-surgical IC, clinically significant anastomotic disease recurrence (Rutgeerts score≥2b) was observed in 38.5% of IPICA vs. 34.2% of APICA, (p=0.820). Excluding patients with stricture at anastomosis (Ri=4s), no failure of small bowel (SB) intubation was observed in IPICA vs. 11 patients (10.5%) in APICA group, yet statistical significance was not met (p=0.216). SB intubation time (defined as time from first image of anastomosis to first image of SB) was significantly shorter for IPICA (1.2±0.9 min) vs. APICA (3.0±3.0 min, p<0.001).

Conclusion

IPICA and APICA are comparable in procedural safety, anastomotic disease recurrence and rate of re-admissions. IPICA necessitates longer surgery time yet allows for significantly easier SB intubation with no intubation failure.

Introduction

Previous studies have shown benefit in performing video capsule endoscopy (VCE) in Crohn’s disease (CD) diagnosis, especially in cases of an unremarkable ileo-colonoscopy, however data on the role of VCE in postsurgical follow-up of CD patients is lacking.

Aims & Methods

Our aim was to evaluate CD endoscopic activity in the small bowel (SB) of patients presenting with disease remission at the ileo-colonic anastomosis.
We retrospectively obtained data on patients with CD older than 18 years of age, who underwent ileo-colonoscopy between the dates 1/10/2012 through 31/09/2022. Patients in whom VCE was performed within 8 months of ileo-colonoscopy were eligible for analysis. Lewis and Rutgeerts scores were calculated based on VCE images and endoscopy reports, respectively. Disease remission was deemed as Rutgeerts score of i0-i1 at the ileo-colonic anastomosis, and Lewis score (LS) of<135 on VCE.

Results

A total of 1,334 ileo-colonoscopies were performed in CD patients with ileo-colonic anastomosis during the study period, of whom 31 patients (male gender 58.06%; mean age 41.77±14.19 years) were referred to VCE within 8 months of ileo-colonoscopy, (median 124.81 days). Twenty patients exhibited endoscopic remission at the anastomosis, 3 of them failed passage of a patency capsule and 17 successfully completed VCE. Only 5 patients (29.4%) had a normal LS, while 12 (70.6%) exhibited an active SB disease (LS≥135, mean 791.3±1254.9). Patients with a discrepancy between the two scores, were characterized by a shorter disease duration (P=0.011) and showed a trend towards a shorter time since surgery (P=0.06). No correlation was found between SB disease activity and concurrent medical therapy (P=0.898). Treatment modification was applied in 7 patients (41.2%) and was associated with a higher LS (biserial correlation coefficient 0.51, P=0.037).

Conclusion

Endoscopic remission at the ileo-colonic anastomosis is not an accurate indicator for CD remission in the SB, especially in a new-onset disease and soon after the surgery. VCE has an added value to ileo-colonoscopy in postsurgical follow-up and treatment adjustment in patients with CD.

Introduction

Patients diagnosed with Crohn's disease (CD) often undergo ileo-colonic resection (ICR) due to disease activity and complications. Post-operative weight gain is common, secondary to reduction in inflammatory burden, resolution of strictures and improved nutrition, yet may result in overweight and obesity (oBMI). Recent studies have shown that obesity in CD may lead to disease exacerbation and decreased response to medical treatment.

Aims & Methods

In this retrospective, case control, single tertiary center study, we aimed to identify risk factors for post-ICR oBMI and to explore the association of post-ICR overweight and obesity with disease recurrence in CD patients. All adult patients with CD who underwent ICR between 1/1/2010 to 31/12/2022 were included. Data collected from hospital records included patients and disease characteristics, post-ICR adverse events and endoscopic recurrence (Rutgeerts score), medical treatment before and after ICR. BMI was recorded at 6-12 months prior to disease exacerbation leading to surgery (baseline-BMI), at ICR and at 12-months post-ICR. Patients with (1) protective or end ileostomy, (2) non-CD exacerbation related surgery (e.g. neoplasia, ischemia), (3) lack of in-hospital IBD clinic follow up, and (4) incomplete BMI records, were excluded. The cohort was divided into two groups by post-ICR BMI [non-overweight BMI (nBMI)<25 kg/m² or oBMI≥25 kg/m²]. Logistic regression model was used and two-sided p-value <0.05 was considered significant.

Results

A total of 94 patients met the inclusion criteria and were included in the study. At 12 months post-ICR, 32 (33.7%) patients had oBMI (mean BMI 28.1±2.8 kg/m²) and 62 (66.3%) had nBMI (mean BMI 21.5±2.1 kg/m²). Groups were comparable in baseline characteristics [Table 1]. Mean baseline-BMI and ICR-BMI were higher in oBMI group compared to nBMI group (26.6±3.3 kg/m² vs. 21.4±2.9 kg/m² at baseline and 24.2±4.0 kg/m² vs. 19.6±2.6 kg/m² at ICR, p<0.001 for both). oBMI patients had a higher rate of ileocolonic (L3) disease (vs. ileal (L1) disease) compared to the nBMI group (62.5% vs 32.3%, p=0.005). No differences were observed in post-operative complications and re-hospitalizations within 12 months of follow up. The rate of endoscopic disease recurrence was comparable within 18 months of ICR (Rutgeerts≥i2b 30.8% for oBMI vs 43.1% for nBMI, p=NS). A logistic regression analysis adjusted to age, gender, and disease location, demonstrated that baseline-BMI, but not ICR-BMI was associated with 12 months post-ICR-oBMI (baseline-BMI: OR 1.699, 95%CI 1.242-2.326, p<0.001; ICR-BMI: OR 1.208, 95%CI 0.932-1.565, p=0.153).

Table 1: Patients' characteristics

Abbreviations: nBMI – non-overweight body mass index; oBMI – overweight/obese body mass index; SD – standard deviation; ICR – ileo-colonic resection; CD – Crohn's disease; n – number

Conclusion

BMI≥25 kg/m² prior to CD exacerbation is associated with post-ICR overweight and obesity. Though at short term follow-up, no increase in postoperative complications and endoscopic disease recurrence were observed, longer follow-up may be needed to assess possible effects of post-ICR overweight and obesity on CD's course.

Introduction

Ileocolic resection is the most common intestinal surgery performed in patients with Crohn’s disease (CD). Despite advances in both surgical techniques and medical therapy, postoperative recurrence remains frequent. Various anastomotic techniques differing in configuration and construction have been proposed to reduce recurrence and postoperative complications. In this study, we aimed to compare laterolateral and end-to-end anastomoses in terms of surgical and medical outcomes following ileocaecal resection in patients with Crohn’s disease.

Aims & Methods

This retrospective study included patients with Crohn’s disease who underwent ileocaecal resection. Patients were divided into two groups based on the type of anastomosis: laterolateral or end-to-end. Clinical, surgical, and postoperative variables were collected and compared. Categorical variables were analyzed using the Chi-square test, while continuous variables were compared using the Student t-test. Endoscopic recurrence was assessed at 6 months using the Rutgeerts score. Univariate and multivariate logistic regression analyses were performed to identify factors associated with endoscopic recurrence.

Results

Among 1,210 patients followed for Crohn’s disease, 221(18.26%) underwent ileocaecal resection. The mean age was 31 ± 12 years, and the female-to-male ratio was 1.24. Tobacco use was reported in 52(23.5%) patients, and a history of appendectomy was noted in 46(20.8%) patients. The inflammatory phenotype (B1) was present in 46(20.9%) patients, the stricturing phenotype (B2) in 95 (43.1%) patients, the penetrating phenotype (B3) in 49 (22.2%) patients, and a combined stricturing and penetrating phenotype in 30(13.7%) patients. Perianal lesions were observed in 67(30.6%) patients.
Corticosteroid use within 4 weeks prior to surgery was reported in 67(30.6%) patients. Use of 5-aminosalicylates was noted in 40(18.2%) patients, immunosuppressants in 74(33.7%) patients, and anti-TNF agents in 50(22.6%) patients.
A total of 136(61.8%) patients underwent ileocaecal resection with a laterolateral anastomosis, while 85(38.2%) received a manual end-to-end anastomosis. The median duration of surgery was 170[120;180] minutes.Ileostomy was performed in 12 (5.4%) patients, while 94.6% underwent immediate restoration of bowel continuity. Postoperatively, 22(10%) patients showed elevated CRP and white blood cell counts, and 19(8.6%) had a Clavien-Dindo score>1.Surgical reintervention was required in 30(13.5%) cases. Clinical recurrence was observed in 38(17.4%) patients, and 60(27%) were initiated on biologic therapy.At 6 months, all patients underwent colonoscopy: 52(23.6%) had Rutgeerts score i0,21(9.7%) had i1, 76(34.7%) had i2, 36(16.6%) had i3, and 33(15.2%) had i4.
When comparing the laterolateral and end-to-end anastomosis groups, statistically significant differences were observed in several parameters: age (38.5vs42 years,p=0.039), duration of surgery>3 hours (4.4%vs9.4%,p<0.001), use of ileostomy (5.8%vs.8.2%,p=0.004), need for surgical reintervention (2.2%vs8.2%,p<0.001), and the presence of a Rutgeerts score ≥ i1 (30.4%vs59.9%,p=0.002). No statistically significant differences were found between the two groups regarding sex, Clavien-Dindo score, or clinical recurrence.
In univariate and multivariate analysis, after adjustment for sex, smoking status, presence of perianal lesions, duration of surgery, restoration of bowel continuity, and postoperative complications,the use of end-to-end anastomosis was associated with an increased risk of endoscopic recurrence (OR = 2.94,95%CI[1.58–25.25],p=0.009).

	Laterolateral anastomosis(N=136)	End-to-end anastomosis(N=85)	p
Sexe Men Women	74(54.8%) 82(60.6%)	39(45.2%) 33(39.4%)	0.441
Age	38.5±13.8	42±14.5	0.039
Long duration of surgery (>3h)	6(4.4%)	8(9.4%)	<0.001
Ileostomy	8(5.8%)	7(8.2%)	0.004
Clavien-Dindo > 1	7(5.1%)	9(10.5%)	0.115
Surgical reintervention	3(2.2%)	7(8.2%)	<0.001
Clinical recurrence	15(11.02%)	8(9.4%)	0.468
Rutgeerts score ≥ i1	41(30.4%)	50(59.6%)	0.468

Conclusion

The choice of anastomotic technique significantly influences postoperative outcomes in Crohn’s disease surgery. In our study, End-to-end anastomosis was associated with longer operative time,higher rates of reintervention, and increased endoscopic recurrence compared to the laterolateral technique. Laterolateral anastomosis offers better postoperative outcomes in ileocaecal resection for Crohn’s disease

Introduction

Early surgical intervention in Crohn’s disease (CD) with inflammatory (B1) phenotype has been shown to be equally successful compared to biologic treatment in the LIR!C study. A recent work by PREDICT IBD group reconfirmed these findings. On the other hand, the prospective multicenter CREOLE study demonstrated long term (>4 years) surgery free survival in stricturing (B2) CD in over 50% of patients, treated with medical and endoscopic therapy. These conflicting findings complicate decision making in the individual patient, and data on conservative management of penetrating CD is lacking.

Aims & Methods

To compare long term outcomes between the early surgery and conservative treatment approach in patients presenting with penetrating (B3) CD.
​This was a retrospective, single tertiary center study, including adult CD patients hospitalized with penetrating abdominal CD, between 1/8/2010 to 30/6/2018. Demographic and clinical data including medical treatment, hospitalization duration, medical and surgical treatments during hospitalization and subsequent hospitalizations and treatments were collected from hospital records. Patients were divided into 2 groups: (1) early surgery (<12 weeks from index hospitalization), and (2) conservative treatment.
Multivariable logistic regression model adjusted for age, sex and smoking status was used for statistical analysis.

Results

A total of 43 CD patients [21 male (48.8%), age 37.9±15.1 years, disease duration 14.1±12.0 years] were hospitalized during the study period for first presentation of penetrating CD [14 (32.6%) with a sinus tract and 29 (67.4%) with an abscess]. Twenty-three patients (53.5%) underwent early surgery (69.5% of whom manifested with abscesses), and the rest were managed non-surgically.
Both groups were similar in terms of CD Montreal classification, smoking status, and type of penetrating complication. Follow up duration was comparable (median 5.2±2.3 years vs 5.3±2.3 years for early surgery vs conservative treatment, respectively, p=0.855).
Exposure to biologics, immunomodulators and glucocorticoids was comparable between the groups before and after index hospitalization.
During the follow up after discharge from the index hospitalization, patients in the surgical group had significantly lower incidence rates of recurrent abscesses (45% vs 4.5%, odds-ratio (OR) 0.04, 95% confidence interval (CI) 0.003-0.40, p=0.006), need for recurrent courses of antibiotics (55.0% vs 14.3%, OR 0.09, 95% CI 0.02-0.53, p=0.07) and recurrent hospitalizations (70.0% vs 39.1%, OR 0.16, 95% CI=0.03-0.72, p=0.017). Two patients (8.7%) in the early surgery group underwent abdominal surgery during follow-up compared to six patients (30.0%) of the conservative treatment group (OR 0.11, 95% CI 0.01-0.92, p=0.04).

Conclusion

In CD patients hospitalized with a penetrating complication, early surgery resulted in significantly less adverse long-term outcomes, such as recurrent abscesses, need for antibiotic treatment, hospitalizations, and surgeries than patients managed conservatively over a median follow up period of 5 years.

Introduction

Ileocecal resection (ICR) is the most common surgical procedure for ileal Crohn's disease (CD). Data is growing to suggest ICR in localized disease as a first-line treatment instead of biologics to maintain long-term remission. However, removal of the ileocecal valve has a detrimental effect on bowel transit and disabling symptoms may occur after surgery. We aimed to assess the impact of a primary ICR on the daily symptoms of patients with CD.

Aims & Methods

All patients who underwent a primary ileocecal resection at the Saint-Antoine Hospital between January 2017 and December 2022 were included. Patients were followed up with post-operative visits before and after Rutgeerts score assessment. Patients' daily symptoms were recorded using a dedicated database (SUVIMIC), the routine software used at the Saint-Antoine Hospital that includes assessment of patient reported outcomes.

Results

Between 2017 and 2022, 110 patients underwent primary ICR for CD in relapse at the Saint-Antoine Hospital. The median disease duration at surgery was 6 years (IQR 1–11). The indications for surgery were fistulizing CD phenotype for 62 patients (56.4%) and strictures for 40 patients (36.4%). Only 7 patients (6.4%) had inflammatory phenotype at the time of first ICR. The median time to Rutgeerts Score assessment was 7 months showing 75 patients (68.2%) in remission defined as a score of i0, i1, i2a and 35 patients (31.8%) in relapse with a score of i2b to i4. Patients' daily symptoms reported at endoscopic assessment (6 – 12 months after surgery) are shown in Table 1. According to disease activity, the prevalence of diarrhea, defined as liquid stools, was 58.7% in patients in remission and 54.3% in patients in relapse. The prevalence of fecal urgency was 22.7% and 25.7%, respectively. Fecal incontinence was present in one patient in remission and three patients in relapse. According to the length of the resected small bowel, liquid stools were observed in 61.7% of patients with short resections (≤ 20 cm), 45.7% of patients with resections between 21 - 40 cm and 76.5% of patients with long resections (≥ 41 cm). Fecal urgency was present in 25.5%, 13.0% and 47.1% respectively. Furthermore, the prevalence of abdominal pain was 31.8% and of fatigue 34.5% in the whole cohort.

Table 1. Daily symptoms of patients after primary ileocecal resection at endoscopic assessment

Symptoms are expressed in number of patients (%). Remission was defined as a Rutgeerts score i0, i1, i2a and relapse i2b, i3 and i4.

Conclusion

The prevalence of digestive symptoms after primary ICR for CD is high, especially diarrhea and fecal urgency, even in patients in remission. Primary ICR for CD is an effective treatment for achieving long-term remission, but removal of the ileocecal valve leads to irreversible changes in bowel transit, which must be considered before proposing surgery.

Introduction

The Rutgeerts score, developed three decades ago, is used to assess postoperative endoscopic recurrence in patients with Crohn’s disease (CD) following ileocolonic resection with an end-to-end anastomosis.¹ However, contemporary surgical techniques have introduced new anatomical locations – the ileal body and ileal inlet – which were not accounted for in the original Rutgeerts score.² Additionally, the original Rutgeerts score has demonstrated limited inter-observer reliability.³ To address these limitations, an updated Rutgeerts score, incorporating new anatomical sites, has been proposed. According to the updated Rutgeerts score lesions restricted to the ileal inlet, or the ileal body can no longer be scored as i2a.² While the updated Rutgeerts score offers improved assessment of inflammation after an ileocolonic resection, its reproducibility has not yet been validated.

Aims & Methods

The aim of our study was to evaluate the inter- and intra-observer reliability of the updated Rutgeerts score.
We conducted a retrospective analysis of 183 patients with CD (48% male, median age 36.8 years) who underwent video-recorded ileocolonoscopy within 14 months of resection with ileocolonic anastomosis. An expert reader MF selected and scored videos of ileocolonoscopies, which were then used as the gold standard. After receiving a two-hour training with a set of ten videos eight expert gastroenterologists reviewed and scored the videos. Each reader assessed 92 videos, including 23 videos that were re-scored after at least one month. Based on the gold standard, inter- and intra-rater agreement was calculated across all score levels and for each score level. Inter-rater reliability was assessed using Fleiss' kappa, and intra-rater reliability using Cohen’s kappa, both with and without application of linear weights.

Results

The probability of perfect agreement between two readers across all scores was 0.604 (95% CI: 0.559-0.649). The chance-corrected inter-observer agreement based on Fleiss’ kappa with linear weights across all scores was 0.619 (95% CI: 0.562-0.676). The strongest inter-observer agreement was observed for the i2a score, with a value of 0.736 (95% CI: 0.647-0.826), while the weakest was seen for the i1 score (0.357, 95%CI: 0.225-0.489).
Intra-rater reliability with a Cohen’s kappa was 0.688 (0.609-0.767), and with weighted kappa was 0.831 (0.758-0.868). The overall agreement rate was 76.0% (69.1%-82.0%).

	Categorical		Ordinal
	Estimate	95%CI	Estimate	95%CI
All levels	0.604	(0.559;0.649)	0.882	(0.866;0.897)
i0	0.633	(0.467;0.800)	0.884	(0.824;0.945)
i1	0.357	(0.225;0.489)	0.829	(0.758;0.899)
i2a	0.736	(0.647;0.826)	0.925	(0.896;0.954)
i2b	0.502	(0.439;0.566)	0.856	(0.834;0.877)
i3	0.487	(0.351;0.623)	0.859	(0.798;0.920)
i4	0.715	(0.606;0.824)	0.894	(0.854;0.934)

Table 1. Summary of agreement across score levels: Agreement for all scores and by individual score levels, based on the gold standard (defined as the scores given by an expert reader MF). Categorical agreement reflects only perfect agreement. Ordinal agreement applies linear weights, assigning less weight to minor disagreements and more to larger ones.

Conclusion

The updated Rutgeerts score demonstrates good agreement and substantial inter- and intra-rater reliability in assessing postoperative endoscopic recurrence in CD, supporting its potential for broader adaptation in both clinical practice and research settings.

References

1. Rutgeerts P, Geboes K, Vantrappen G, Beyls J, Kerremans R, Hiele M. Predictability of the postoperative course of Crohn’s disease. Gastroenterology. 1990;99(4):956-963. doi:10.1016/0016-5085(90)90613-6
2. Rivière P, Bislenghi G, Vermeire S, et al. Postoperative Crohn’s Disease Recurrence: Time to Adapt Endoscopic Recurrence Scores to the Leading Surgical Techniques. Clin Gastroenterol Hepatol. 2022;20(6):1201-1204. doi:10.1016/j.cgh.2022.02.025
3. Marteau P, Laharie D, Colombel JF, et al. Interobserver Variation Study of the Rutgeerts Score to Assess Endoscopic Recurrence after Surgery for Crohn’s Disease. Journal of Crohn’s and Colitis. 2016;10(9):1001-1005. doi:10.1093/ecco-jcc/jjw082