Surgical treatment of Crohn's disease

Research output: ThesisDoctoral ThesisCollection of Articles

Abstract

Background: Crohn’s disease (CD) is a chronic inflammatory bowel disease that can affect any part of the gastrointestinal tract. It most commonly affects the terminal ileum and causes transmural inflammation of the bowel wall resulting in stenosis, fistula or abscess formation. Medication is the treatment of choice for CD, although most patients will require surgery at some point as a result of the disease. Aims: We compared preoperative magnetic resonance enterography (MRE) findings with surgical findings. We also assessed whether the presence of inflammatory activity at the bowel resection margin affected postoperative anastomotic complications in CD patients. Our study evaluated the risk factors for anastomotic recurrence after primary ileocaecal resection and compared surgical recurrence after different types of bowel resection in CD patients. Patients and methods: Our patient sample comprised of 249 consecutive CD patients undergoing surgery at the Helsinki University Hospital during 2006 and 2016. We applied a series of inclusion criteria to each study. Study I consisted of 55 patients who underwent preoperative MRE within the four months preceding surgery between 2011 and 2015. Study II consisted of 70 patients with available bowel resection margins operated on between 2011 and 2015. Study III consisted of 101 patients submitted to primary ileocaecal resection. Study IV consisted of all CD patients undergoing bowel resection with available postoperative follow-up information, yielding 218 patients. Results: Preoperative MRE sensitivity compared to surgical findings was 100%, 77.8% and 80.0% while the specificity was 77.8%, 83.8% and 90.0%, respectively, for stenosis, fistula and abscess and calculated per patient. The operative plan was modified for 7 patients due to an erroneous preoperative MRE diagnosis of lesions compared to surgical findings. The MRE diagnosis did not agree with the surgical findings for 36 lesions. Furthermore, adhesions were responsible for 44.4% of the incorrect MRE diagnoses. 46 patients (65.7%) had inflammatory activity in the bowel resection margin. Postoperative complications were detected in 14 patients (20%), among whom 3 (4.3%) experienced anastomotic complications. The presence of inflammatory activity in the bowel resection margin did not significantly influence the occurrence of anastomotic complications. Among 101 patients undergoing primary ileocaecal resection in our unit, 9 patients were excluded from analysis due to a follow-up of <1 year. An end-to-end hand-sewn anastomosis was performed on 96.7% of the patients. Anastomotic recurrence occurred in 12 patients (13%). Urgent surgery, stapled anastomosis and the need for postoperative steroids emerged as risk factors for anastomotic recurrence. The frequency of surgical recurrence according to the type of the primary operation performed was as follows: 14 patients (10.1%) after an ileocolic resection, 6 patients (25.0%) after a small bowel resection, 7 patients (41.2%) after a segmental colon resection with colocolic anastomosis or left colon resection, 3 patients (75.0%) after a colectomy with ileorectal anastomosis and 12 patients (34.3%) after an end stoma operation. The CD location at the reoperation correlated with the location of the primary operation. Conclusions: MRE represents a useful preoperative diagnostic tool for CD, although the presence of intra-abdominal adhesions may cause incorrect diagnosis using MRE. Inflammatory activity at the resection margins did not significantly influence the development of postoperative anastomotic complications, encouraging the use of bowel-sparing surgical techniques for CD. After primary ileocaecal resection, we found a 1.1% anastomotic recurrence rate at 1 year. Hand-sewn anastomosis with an opening of the bowel antimesenteric border appears to be a safe choice after ileocolic resection. In addition, ileocolic resection carries a lower risk of surgical recurrence than other types of bowel resections for CD.
Original languageEnglish
Supervisors/Advisors
  • Lepistö, Anna Henriikka, Supervisor
Award date26 Oct 2018
Place of PublicationHelsinki
Publisher
Print ISBNs978-951-51-4454-6
Electronic ISBNs978-951-51-4455-3
Publication statusPublished - 2018
MoE publication typeG5 Doctoral dissertation (article)

Fields of Science

  • Fistula
  • +diagnostic imaging
  • Constriction, Pathologic
  • Postoperative Complications
  • Anastomosis, Surgical
  • Reoperation
  • Colectomy
  • 3126 Surgery, anesthesiology, intensive care, radiology
  • 3121 Internal medicine

Cite this

Aaltonen, G. (2018). Surgical treatment of Crohn's disease. Helsinki: [G. Aaltonen].
Aaltonen, Gisele. / Surgical treatment of Crohn's disease. Helsinki : [G. Aaltonen], 2018. 93 p.
@phdthesis{045bf6cb3a8742dea1d3cba7b087a95d,
title = "Surgical treatment of Crohn's disease",
abstract = "Background: Crohn’s disease (CD) is a chronic inflammatory bowel disease that can affect any part of the gastrointestinal tract. It most commonly affects the terminal ileum and causes transmural inflammation of the bowel wall resulting in stenosis, fistula or abscess formation. Medication is the treatment of choice for CD, although most patients will require surgery at some point as a result of the disease. Aims: We compared preoperative magnetic resonance enterography (MRE) findings with surgical findings. We also assessed whether the presence of inflammatory activity at the bowel resection margin affected postoperative anastomotic complications in CD patients. Our study evaluated the risk factors for anastomotic recurrence after primary ileocaecal resection and compared surgical recurrence after different types of bowel resection in CD patients. Patients and methods: Our patient sample comprised of 249 consecutive CD patients undergoing surgery at the Helsinki University Hospital during 2006 and 2016. We applied a series of inclusion criteria to each study. Study I consisted of 55 patients who underwent preoperative MRE within the four months preceding surgery between 2011 and 2015. Study II consisted of 70 patients with available bowel resection margins operated on between 2011 and 2015. Study III consisted of 101 patients submitted to primary ileocaecal resection. Study IV consisted of all CD patients undergoing bowel resection with available postoperative follow-up information, yielding 218 patients. Results: Preoperative MRE sensitivity compared to surgical findings was 100{\%}, 77.8{\%} and 80.0{\%} while the specificity was 77.8{\%}, 83.8{\%} and 90.0{\%}, respectively, for stenosis, fistula and abscess and calculated per patient. The operative plan was modified for 7 patients due to an erroneous preoperative MRE diagnosis of lesions compared to surgical findings. The MRE diagnosis did not agree with the surgical findings for 36 lesions. Furthermore, adhesions were responsible for 44.4{\%} of the incorrect MRE diagnoses. 46 patients (65.7{\%}) had inflammatory activity in the bowel resection margin. Postoperative complications were detected in 14 patients (20{\%}), among whom 3 (4.3{\%}) experienced anastomotic complications. The presence of inflammatory activity in the bowel resection margin did not significantly influence the occurrence of anastomotic complications. Among 101 patients undergoing primary ileocaecal resection in our unit, 9 patients were excluded from analysis due to a follow-up of <1 year. An end-to-end hand-sewn anastomosis was performed on 96.7{\%} of the patients. Anastomotic recurrence occurred in 12 patients (13{\%}). Urgent surgery, stapled anastomosis and the need for postoperative steroids emerged as risk factors for anastomotic recurrence. The frequency of surgical recurrence according to the type of the primary operation performed was as follows: 14 patients (10.1{\%}) after an ileocolic resection, 6 patients (25.0{\%}) after a small bowel resection, 7 patients (41.2{\%}) after a segmental colon resection with colocolic anastomosis or left colon resection, 3 patients (75.0{\%}) after a colectomy with ileorectal anastomosis and 12 patients (34.3{\%}) after an end stoma operation. The CD location at the reoperation correlated with the location of the primary operation. Conclusions: MRE represents a useful preoperative diagnostic tool for CD, although the presence of intra-abdominal adhesions may cause incorrect diagnosis using MRE. Inflammatory activity at the resection margins did not significantly influence the development of postoperative anastomotic complications, encouraging the use of bowel-sparing surgical techniques for CD. After primary ileocaecal resection, we found a 1.1{\%} anastomotic recurrence rate at 1 year. Hand-sewn anastomosis with an opening of the bowel antimesenteric border appears to be a safe choice after ileocolic resection. In addition, ileocolic resection carries a lower risk of surgical recurrence than other types of bowel resections for CD.",
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author = "Gisele Aaltonen",
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Surgical treatment of Crohn's disease. / Aaltonen, Gisele.

Helsinki : [G. Aaltonen], 2018. 93 p.

Research output: ThesisDoctoral ThesisCollection of Articles

TY - THES

T1 - Surgical treatment of Crohn's disease

AU - Aaltonen, Gisele

N1 - M1 - 93 s. + liitteet

PY - 2018

Y1 - 2018

N2 - Background: Crohn’s disease (CD) is a chronic inflammatory bowel disease that can affect any part of the gastrointestinal tract. It most commonly affects the terminal ileum and causes transmural inflammation of the bowel wall resulting in stenosis, fistula or abscess formation. Medication is the treatment of choice for CD, although most patients will require surgery at some point as a result of the disease. Aims: We compared preoperative magnetic resonance enterography (MRE) findings with surgical findings. We also assessed whether the presence of inflammatory activity at the bowel resection margin affected postoperative anastomotic complications in CD patients. Our study evaluated the risk factors for anastomotic recurrence after primary ileocaecal resection and compared surgical recurrence after different types of bowel resection in CD patients. Patients and methods: Our patient sample comprised of 249 consecutive CD patients undergoing surgery at the Helsinki University Hospital during 2006 and 2016. We applied a series of inclusion criteria to each study. Study I consisted of 55 patients who underwent preoperative MRE within the four months preceding surgery between 2011 and 2015. Study II consisted of 70 patients with available bowel resection margins operated on between 2011 and 2015. Study III consisted of 101 patients submitted to primary ileocaecal resection. Study IV consisted of all CD patients undergoing bowel resection with available postoperative follow-up information, yielding 218 patients. Results: Preoperative MRE sensitivity compared to surgical findings was 100%, 77.8% and 80.0% while the specificity was 77.8%, 83.8% and 90.0%, respectively, for stenosis, fistula and abscess and calculated per patient. The operative plan was modified for 7 patients due to an erroneous preoperative MRE diagnosis of lesions compared to surgical findings. The MRE diagnosis did not agree with the surgical findings for 36 lesions. Furthermore, adhesions were responsible for 44.4% of the incorrect MRE diagnoses. 46 patients (65.7%) had inflammatory activity in the bowel resection margin. Postoperative complications were detected in 14 patients (20%), among whom 3 (4.3%) experienced anastomotic complications. The presence of inflammatory activity in the bowel resection margin did not significantly influence the occurrence of anastomotic complications. Among 101 patients undergoing primary ileocaecal resection in our unit, 9 patients were excluded from analysis due to a follow-up of <1 year. An end-to-end hand-sewn anastomosis was performed on 96.7% of the patients. Anastomotic recurrence occurred in 12 patients (13%). Urgent surgery, stapled anastomosis and the need for postoperative steroids emerged as risk factors for anastomotic recurrence. The frequency of surgical recurrence according to the type of the primary operation performed was as follows: 14 patients (10.1%) after an ileocolic resection, 6 patients (25.0%) after a small bowel resection, 7 patients (41.2%) after a segmental colon resection with colocolic anastomosis or left colon resection, 3 patients (75.0%) after a colectomy with ileorectal anastomosis and 12 patients (34.3%) after an end stoma operation. The CD location at the reoperation correlated with the location of the primary operation. Conclusions: MRE represents a useful preoperative diagnostic tool for CD, although the presence of intra-abdominal adhesions may cause incorrect diagnosis using MRE. Inflammatory activity at the resection margins did not significantly influence the development of postoperative anastomotic complications, encouraging the use of bowel-sparing surgical techniques for CD. After primary ileocaecal resection, we found a 1.1% anastomotic recurrence rate at 1 year. Hand-sewn anastomosis with an opening of the bowel antimesenteric border appears to be a safe choice after ileocolic resection. In addition, ileocolic resection carries a lower risk of surgical recurrence than other types of bowel resections for CD.

AB - Background: Crohn’s disease (CD) is a chronic inflammatory bowel disease that can affect any part of the gastrointestinal tract. It most commonly affects the terminal ileum and causes transmural inflammation of the bowel wall resulting in stenosis, fistula or abscess formation. Medication is the treatment of choice for CD, although most patients will require surgery at some point as a result of the disease. Aims: We compared preoperative magnetic resonance enterography (MRE) findings with surgical findings. We also assessed whether the presence of inflammatory activity at the bowel resection margin affected postoperative anastomotic complications in CD patients. Our study evaluated the risk factors for anastomotic recurrence after primary ileocaecal resection and compared surgical recurrence after different types of bowel resection in CD patients. Patients and methods: Our patient sample comprised of 249 consecutive CD patients undergoing surgery at the Helsinki University Hospital during 2006 and 2016. We applied a series of inclusion criteria to each study. Study I consisted of 55 patients who underwent preoperative MRE within the four months preceding surgery between 2011 and 2015. Study II consisted of 70 patients with available bowel resection margins operated on between 2011 and 2015. Study III consisted of 101 patients submitted to primary ileocaecal resection. Study IV consisted of all CD patients undergoing bowel resection with available postoperative follow-up information, yielding 218 patients. Results: Preoperative MRE sensitivity compared to surgical findings was 100%, 77.8% and 80.0% while the specificity was 77.8%, 83.8% and 90.0%, respectively, for stenosis, fistula and abscess and calculated per patient. The operative plan was modified for 7 patients due to an erroneous preoperative MRE diagnosis of lesions compared to surgical findings. The MRE diagnosis did not agree with the surgical findings for 36 lesions. Furthermore, adhesions were responsible for 44.4% of the incorrect MRE diagnoses. 46 patients (65.7%) had inflammatory activity in the bowel resection margin. Postoperative complications were detected in 14 patients (20%), among whom 3 (4.3%) experienced anastomotic complications. The presence of inflammatory activity in the bowel resection margin did not significantly influence the occurrence of anastomotic complications. Among 101 patients undergoing primary ileocaecal resection in our unit, 9 patients were excluded from analysis due to a follow-up of <1 year. An end-to-end hand-sewn anastomosis was performed on 96.7% of the patients. Anastomotic recurrence occurred in 12 patients (13%). Urgent surgery, stapled anastomosis and the need for postoperative steroids emerged as risk factors for anastomotic recurrence. The frequency of surgical recurrence according to the type of the primary operation performed was as follows: 14 patients (10.1%) after an ileocolic resection, 6 patients (25.0%) after a small bowel resection, 7 patients (41.2%) after a segmental colon resection with colocolic anastomosis or left colon resection, 3 patients (75.0%) after a colectomy with ileorectal anastomosis and 12 patients (34.3%) after an end stoma operation. The CD location at the reoperation correlated with the location of the primary operation. Conclusions: MRE represents a useful preoperative diagnostic tool for CD, although the presence of intra-abdominal adhesions may cause incorrect diagnosis using MRE. Inflammatory activity at the resection margins did not significantly influence the development of postoperative anastomotic complications, encouraging the use of bowel-sparing surgical techniques for CD. After primary ileocaecal resection, we found a 1.1% anastomotic recurrence rate at 1 year. Hand-sewn anastomosis with an opening of the bowel antimesenteric border appears to be a safe choice after ileocolic resection. In addition, ileocolic resection carries a lower risk of surgical recurrence than other types of bowel resections for CD.

KW - Fistula

KW - +diagnostic imaging

KW - Constriction, Pathologic

KW - Postoperative Complications

KW - Anastomosis, Surgical

KW - Reoperation

KW - Colectomy

KW - 3126 Surgery, anesthesiology, intensive care, radiology

KW - 3121 Internal medicine

M3 - Doctoral Thesis

SN - 978-951-51-4454-6

PB - [G. Aaltonen]

CY - Helsinki

ER -

Aaltonen G. Surgical treatment of Crohn's disease. Helsinki: [G. Aaltonen], 2018. 93 p.