Introduction
The clinical course after surgery in Crohn’s Disease (CD) patients ileo-colonic anastomosis (ICA) is well known. Differently, clinical outcome in patients with entero-enteric anastomosis (EEA) after isolated small bowel resection is undefined.
Aims & Methods
The primary aim of the present case-control study was to search for differences in terms of major clinical outcomes at 5 years between CD patients with EEA (Cases), when compared to CD patients with ICA (Controls) matched for age and smoking status before index surgery. Secondary aim was to compare the characteristics of CD and the disease course before index surgery in Cases versus Controls.
All CD patients with EEA were retrospectively enrolled and matched for age at diagnosis (+/- 5 years) and smoking status before index surgery with 2 CD Controls with ICA. Inclusion criteria: 1) age ≥18; 2) EEA or ICA for CD; 3) ≥5-years follow-up after index surgery. Exclusion criteria: 1) missing data; 2) ostomy; 3) stricturoplasty. Data were expressed as median [range]. The Student-t-test, X2 test, Kaplan-Meier curves and logistic regression analyses were used as appropriate.
Results
Cases included 51 CD patients with EEA (ileum-ileum 39 [76.5%], jejunum-ileum 6 [11.8%], jejunum-jejunum 5 [9.8%], duodenum-jejunum 1 [1.9%]). Matched Controls included 102 CD patients with ICA. At 3 and 5 years after surgery, clinical recurrence was more frequent in Cases (28 [54.9%] vs. 37 [36.3%], p=0.04; 34 [66.7%] vs. 43 [42.2%], p=0.007). Cases showed a higher frequency of CD-related hospitalization ≤5 years after surgery (25 [49%] vs. 23 [22.5%], p=0.001]) (Table). In Cases, corticosteroids use was more frequent at 1, 3 and 5 years (14 [27.5%] vs. 8 [7.8%], p=0.002; 21 [41.2%] vs. 15 [14.7%], p=0.0006; 26 [50.9%] vs. 18 [17.6%], p<0.0001) (Table). ISS and biologics use 3 and 5 years after surgery was more frequent in Cases (20 [39.2%] vs. 20 [19.6%], p=0.01; 21 [41.2%] vs. 24 [23.5%], p=0.03; (15 [29.4%] vs. 13 [12.7%], p=0.02 and 23 [45.1%] vs. 15 [14.7%], p=0.03) (Table). Cases showed a shorter time to survival from clinical recurrence and hospitalization (2.36 [1.29-4.35], p=0.0036; 1.71 [1.06-2.77], p=0.02). EEA and ISS use before index surgery were risk factors for CD-related hospitalization and clinical recurrence at 5 years (2.68 [1.11-6.45]; p=0.02, 2.61 [1.21-5.6]; p=0.01 and 2.53 [1.05-6.09]; p=0.03; 2.44 [1.18-5]; p=0.01).
| | Entero-Enteric Anastomosis
(n=51) | Ileo-Colonic Anastomosis
(n=102) | p |
Crohn’s Disease-related surgery after index surgery, n (%)
At 1 year
At 3 years
At 5 years |
1 (1.9%)
4 (7.8%)
9 (17.6%) |
6 (5.9%)
7 (6.9%)
9 (8.8%) |
0.49
0.91
0.18 |
Clinical recurrence
At 1 year
At 3 years
At 5 years |
17 (33.3%)
28 (54.9%)
34 (66.7%) |
23 (22.5%)
37 (36.3%)
43 (42.2%) |
0.21
0.04
0.007 |
Hospitalization, n (%)
At 1 year
At 3 years
At 5 years |
7 (13.7%)
15 (29.5%)
25 (49%) |
13 (12.7%)
17 (16.7%)
23 (22.5%) |
0.93
0.1
0.001 |
Corticosteroids
At 1 year
At 3 years
At 5 years |
14 (27.5%)
19 (37.3%)
26 (51%) |
8 (7.8%)
15 (14.7%)
18 (17.6%) |
0.002
0.003
<0.0001 |
Conventional immunosuppressors
At 1 year
At 3 years
At 5 years |
12 (23.5%)
20 (39.2%)
21 (41.2%) |
16 (15.7%)
20 (19.6%)
24 (23.5%) |
0.33
0.01
0.03 |
Biologics
At 1 year
At 3 years
At 5 years |
10 (19.6%)
15 (29.4%)
23 (45.1%) |
9 (8.8%)
13 (12.7%)
15 (14.7%) |
0.09
0.02
0.03 |
Conclusion
The clinical outcome after surgery is more severe in CD patients with EEA versus ICA, being associated with a higher rate of clinical recurrence, hospitalization and need of major treatments for the disease. This suggests the need of a tight assessment after isolated small bowel surgery, in order to achieve a timely and appropriate treatment and possible prevention of complications.
References
1) Onali S, Petruzziello C, Calabrese E, Condino G, Zorzi F, Sica GS, Pallone F, Biancone L. Frequency, pattern, and risk factors of postoperative recurrence of Crohn's disease after resection different from ileo-colonic. J Gastrointest Surg. 2009; 13 (2): 246-252.
2) Bemelman WA, Warusavitarne J, Sampietro GM, Serclova Z, Zmora O, Luglio G, de Buck van Overstraeten A, Burke JP, Buskens CJ, Francesco C, et al. ECCO-ESCP Consensus on Surgery for Crohn’s Disease. J. Crohns Colitis. 2017; 12: 1-16.