Factors Associated with Short-Term Morbidity in Patients Undergoing Colon Resection for Crohn’s Disease

Background

Patients undergoing colon resection for Crohn’s disease are at risk of developing postoperative complications. The aim of this study is to identify factors associated with short-term (30-day) morbidity in patients undergoing colon resection for Crohn’s disease from a national database.

Methods

Patients who underwent colon resection for Crohn’s disease in 2015 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The groups were classified based on presence of postoperative 30-day complications. The overall morbidity was calculated by including patients who had at least one postoperative complication. Demographics, preoperative, and operative factors were assessed and compared between the two groups. Further multivariate logistic regression analysis was conducted.

Results

A total of 1643 patients met the inclusion criteria [mean age of 41.2 (±?15.5) years, 871 (53%) female]. Sixty percent (n?=?993) of the procedures were performed laparoscopically and 128 (12.8%) cases were converted to open. Ninety-five patients (5%) underwent emergent resections. Thirty percent (n?=?507) of patients had at least one postoperative complication within 30 days of surgery. Ileus (16%), transfusion (7%), and organ-space surgical site infection (6%) were the most common morbidities. Independent risk factors for postoperative morbidity were male gender (p?=?0.01), open surgery (p?=?0.002), preoperative severe anemia (p?=?0.001), and preoperative weight loss (p?=?0.04).

Conclusion

Approximately one third of the patients who undergo colon resection for Crohn’s disease experience postoperative complications. Preoperative optimization of nutrition and anemia may improve outcomes. Laparoscopic technique appears to be the preferred surgical treatment option for resection when feasible.

     

Intra-abdominal Fistulas in Surgically Treated Crohn’s Disease Patients

Background  

Intra-abdominal fistulas occur in one-third of patients with Crohn’s disease (CD). Although they are common, these fistulas may pose difficult problems for the surgeon. We assessed the clinical presentation of intra-abdominal fistulas in patients with CD and compared the clinicopathologic characteristics of CD with and without fistulas.     

Pre-Colectomy Appendectomy and Risk for Crohn’s Disease in Patients with Ileal Pouch-Anal Anastomosis

Background

A subset of patients with a pre-operative diagnosis of ulcerative colitis can develop Crohn??s disease (CD) of the pouch after restorative proctocolectomy. While appendectomy has been implicated to be associated with an increased risk for CD, its impact on the development of de novo CD of the pouch in patients?? ileal pouch-anal anastomosis (IPAA) has not been studied. The aims of the study were to assess the prevalence of CD of the pouch in patients with pre-colectomy appendectomy and to investigate the impact of appendectomy on the development of de novo CD of the pouch.

Methods

All eligible patients with restorative proctocolectomy and IPAA for IBD who had available information on pre-colectomy appendectomy were studied. Demographic and clinical characteristics were evaluated. Cox regression analysis was performed.

Results

The study included 434 patients (44.9?% male) with a mean age of 45.2?±?14.4?years and follow-up of 4.6?±?2.3?years. Forty patients (9.2?%) had had appendectomy prior to colectomy. Appendectomy was not shown to be associated with CD of the pouch or its phenotypes in both univariable and multivariable analyses. In the Cox model, independent risk factors associated with CD of the pouch were active smoking (hazard ratio [HR]?=?1.58; 95?% confidence interval [CI], 1.03?C2.43) and family history of CD (HR?=?1.82; 95?% CI, 0.99?C3.32).

Conclusions

While this study has shown no association between previous appendectomy and the development of CD of pouch, active smoking was an independent risk factor for development of CD of the pouch.     

Frequency and Risk Factors of Postoperative Recurrence of Crohn’s Disease After Intestinal Resection in the Chinese Population

Background

Data on risk factors of postoperative recurrence in patients with Crohn??s disease (CD) have shown conflicting results. The aim of this retrospective study is to identify predictors of early symptomatic recurrence of CD after surgical intestinal resection in the Chinese population.

Materials and Methods

Patients diagnosed as CD who underwent intestinal resection in Jinling Hospital between May 2004 and December 2010 were included in our study. Clinical data of these patients were reviewed. Multivariable survival analysis was performed to elucidate risk factors of early postoperative symptomatic recurrence.

Results

There were a total of 141 CD patients who had at least one previous curative resection for CD under regular follow-up in our unit. Our data indicated disease behavior (95?% CI 1.01?C1.70, P?=?0.044), smoking habits (95?% CI 1.32?C2.84, P?=?0.001), indication of perforation (95?% CI 1.09?C4.02, P?=?0.026), and location of anastomosis (95?% CI 1.09?C3.39, P?=?0.023) which are, as a result, strong independent predictors of symptomatic recurrence, while the anastomosis type as side-to-side anastomosis (SSA) was significantly associated with a decreased risk of symptomatic recurrence when compared with other anastomosis type (95?% CI 0.26?C0.94, P?=?0.038). Medical prophylaxes also played a role in the prevention of postoperative symptomatic recurrence.

Conclusions

A smoking habits and perforation indication for surgery at the time of resection are associated with an increased risk of symptomatic recurrence. Anastomosis type with SSA is associated with a reduced risk of symptomatic recurrence. This population-based study supports the concept that environmental factors, disease character, and surgical technique influence the risk of postoperative symptomatic recurrence of CD.     

Intestinal Cancer Risk in Crohn’s Disease: A Meta-Analysis

Aim of the study  

To clarify the intestinal cancer risk in Crohn’s disease (CD).     

Cavernous Transformation of the Portal Vein Causing Jaundice,Presenting in the Form of Wilson’s Disease

The following is a case review of portal vein cavernous malformation presenting with intermittent cholestasis and jaundice in a 4 year old child. Correct assessment was supported by radiology, later laparoscopy, yet hindered by histopathology representative Wilson’s disease and elevated urinary copper excretion. During surgical procedure the stenosis of the common bile duct secondary to extremely dilated portal vein reticulation was solved by Roux-en-Y choledochojejunostomy. After a one-year follow up the child remains asymptomatic.     

Surgical Complications Following Liver Transplantation in Patients with Portal Vein Thrombosis—A Single-Center Perspective

Introduction

Portal vein thrombosis (PVT) was once considered a contraindication for liver transplantation (LTx) because of technical difficulties. Though no longer a contraindication, it remains a risk factor.

Aim

A study of surgical complications following LTx in patients with and without PVT.

Patients and methods

A retrospective review of 1,171 consecutive patients who underwent LTx between June 1995 and June 2007 was performed, and 78 recipients with PVT (study group) were compared with a stratified random sample of 78 contemporous recipients without PVT (control group) for postoperative complications. Both groups were comparable with respect to age, sex, race, and other confounding variables.

Results

The rate of primary nonfunction (PNF) in the study and control groups was 9.0% and 1.3%, (p?=?0.063), while that of retransplantation was 17.9% and 7.7% (p?=?0.055), respectively. The mean donor risk index (DRI) among the patients with and without PNF in the study group was 2.58?±?0.44 and 2.08?±?0.42, respectively (p?=?0.014). A significantly higher number of packed red blood cells and fresh frozen plasma transfusions were observed in study group compared to controls (p?=?0.012, 0.007, respectively).

Conclusion

A higher rate of PNF was related to the complexity of the surgical procedure and the use of donor livers with a high DRI. Higher rates of PNF eventually led to a higher rate of retransplant. A strategy of offering donor livers with a low DRI might be helpful in decreasing the rate of PNF. Further, a PV interposition graft in difficult cases instead of thrombectomy could lead to a lower rethrombosis rate.     

Predictive Factors of Thyroid Cancer in Patients with Graves’ Disease

Background

The best preoperative examination in Graves’ disease with thyroid cancer still remains uncertain. The objectives of the present study were to investigate the prevalence of thyroid cancer in Graves’ disease patients, and to identify the predictive factors and ultrasonographic features of thyroid cancer that may aid the preoperative diagnosis in Graves’ disease.

Methods

This retrospective study included 423 patients with Graves’ disease who underwent surgical treatment from 2002 to 2012 at our institution. The clinical features and ultrasonographic findings of thyroid nodules were recorded. The diagnosis of thyroid cancer was determined according to the pathological results.

Results

Thyroid cancer was discovered in 58 of the 423 (13.7 %) surgically treated Graves’ disease patients; 46 of those 58 patients had thyroid nodules, and the other 12 patients were diagnosed with incidentally discovered thyroid carcinomas without thyroid nodules. Among the 58 patients with thyroid cancer, papillary microcarcinomas were discovered in 50 patients, and multifocality and lymph node involvement were detected in the other 8 patients. Multivariate regression analysis showed younger age was the only significant factor predictive of metastatic thyroid cancer. Ultrasonographic findings of calcification and intranodular blood flow in thyroid nodules indicate that they are more likely to harbor thyroid cancers.

Conclusions

Because the influencing factor of metastatic thyroid cancers in Graves’ disease is young age, every suspicious nodule in Graves’ disease patients should be evaluated and treated carefully, especially in younger patients because of the potential for metastasis.     

Small Bowel Adenocarcinoma in Crohn’s Disease

Background  

An association between small bowel adenocarcinoma and Crohn’s disease (CD) is well-established. We present our recent experience with this entity in order to further elucidate its clinicopathological features and update our series from 1991.     

Outcome of Surgery for Coloduodenal Fistula in Crohn’s Disease

Background

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.

Methods

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.

Results

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.

Conclusion

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.

     

Readmission After Abdominal Surgery for Crohn’s Disease: Identification of High-Risk Patients

Background

Although many predictive factors for postoperative morbidity are known, few data are available about readmission after abdominal surgery for Crohn’s disease (CD). The objective of this study is to identify predictive factors and high-risk patients for readmission after abdominal CD surgery.

Methods

All patients who underwent abdominal surgery for CD in one tertiary referral center between January 2004 and December 2016 were included. Patients who required readmission and those without were compared. Perineal procedures, elective readmissions, and abdominal procedures for non-Crohn’s indications were not included.

Results

Nine hundred eight abdominal procedures were performed in 712 patients. Readmission rates were 8, 8.5, 8.6, 8.8, and 8.9% at 30, 60, and 90 days and 12 and 60 months, respectively. The main reasons were wound infection (14%), deep abscess (13%), small-bowel obstruction (13%), and dehydration (11%). Eight (11%) patients required percutaneous drainage and 19 (27%) underwent an unplanned surgery. After multivariate analysis, three independent predictive factors for readmission were identified: older age (OR 1.02, 95%CI 1.005–1.04; p?<?0.006), a history of previous proctectomy (OR 3, 95%CI 1.2–9, p?<?0.02), and higher blood loss volume during surgery (OR 1.0001, 95%CI 1–1.002, p?<?0.05).

Conclusion

Readmission occurred in 8–9% of abdominal procedures for CD within 1–3 months after surgery and it required unplanned reoperation in a quarter of them. Identification of high-risk groups and knowledge of the more common postoperative complications requiring readmission help in increasing postoperative vigilance to select patients who may benefit from early interventions.

     

Surgical Considerations in the Treatment of Small Bowel Crohn’s Disease

Journal of Gastrointestinal Surgery - Surgery remains a cornerstone of the management of Crohn’s disease (CD). Despite the rise of biologic therapy, most CD patients require surgery for...     

An Envirogenomic Signature Is Associated with Risk of IBD-Related Surgery in a Population-Based Crohn’s Disease Cohort

Background and Aims

Crohn’s disease (CD) is an inflammatory bowel disease (IBD) caused by a combination of genetic, clinical, and environmental factors. Identification of CD patients at high risk of requiring surgery may assist clinicians to decide on a top–down or step-up treatment approach.

Methods

We conducted a retrospective case–control analysis of a population-based cohort of 503 CD patients. A regression-based data reduction approach was used to systematically analyse 63 genomic, clinical and environmental factors for association with IBD-related surgery as the primary outcome variable.

Results

A multi-factor model was identified that yielded the highest predictive accuracy for need for surgery. The factors included in the model were the NOD2 genotype (OR?=?1.607, P?=?2.3?×?10^?5), having ever had perianal disease (OR?=?2.847, P?=?4?×?10^?6), being post-diagnosis smokers (OR?=?6.312, P?=?7.4?×?10^?3), being an ex-smoker at diagnosis (OR?=?2.405, P?=?1.1?×?10^?3) and age (OR?=?1.012, P?=?4.4?×?10^?3). Diagnostic testing for this multi-factor model produced an area under the curve of 0.681 (P?=?1?×?10^?4) and an odds ratio of 3.169, (95 % CI P?=?1?×?10^?4) which was higher than any factor considered independently.

Conclusions

The results of this study require validation in other populations but represent a step forward in the development of more accurate prognostic tests for clinicians to prescribe the most optimal treatment approach for complicated CD patients.     

Factors Associated with Operative Recurrence Early After Resection for Crohn’s Disease

Introduction  

Some Crohn’s disease (CD) patients develop rapid disease recurrence requiring reoperation. Identification of factors associated with early operative recurrence of CD may help risk-stratify patients and prevent recurrence.     

Enteroliths in Crohn’s Disease: a Case Report

Subtraction angiography is an invasive diagnostic method, which for a long time was a gold standard in carotid artery and intra-cranial vessel imaging. The aim of this research is to evaluate angiographic imaging in predicting atherosclerotic plaque type VI by AHA morphology and to assess its significance in establishing patients’ suitability for a particular operative method. Secondarily, we assessed atherosclerotic lesions in common carotid artery bifurcation. In the paper we analyzed 158 bilateral angiograms of common and internal carotid arteries in extra-and intra-cranial locations.

The material consisted of patients hospitalized in the Vascular Surgery Ward of Memorial Copernicus Hospital in Lodz during 2002–2004 who underwent angiography. We concluded that: 1. In symptomatic patients irregular plaque images in subtraction angiography is correlated with plaque type VI by AHA morphology. 2. Angiography is not a sufficient method for selection of the appropriate operative treatment due to its low sensitivity and specificity in plaque morphology imaging. 3. Plaque type VI by AHA is characteristic even for the second group of carotid bifurcation stenosis (by NASCET) and it definitely dominates in group III (by NASCET).