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Temporary faecal diversion in ileocolic resection for Crohns disease: is there an impact on long-term surgical recurrence?
Oxford Univ Hosp NHS Fdn Trust, England.
Oxford Univ Hosp NHS Fdn Trust, England.
Oxford Univ Hosp NHS Fdn Trust, England.
St Marks Hosp, England.
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2020 (English)In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 22, no 4, p. 430-438Article in journal (Refereed) Published
Abstract [en]

Aim Temporary faecal diversion after ileocolic resection (ICR) for Crohns disease reduces postoperative anastomotic complications in high-risk patients. The aim of this study was to assess if this approach also reduces long-term surgical recurrence. Method This was a multicentre retrospective review of prospectively maintained databases. Patient demographics, medical and surgical details were collected by three specialist centres. All patients had undergone an ICR between 2000 and 2012. The primary end-point was surgical recurrence. Results Three hundred and twelve patients (80%) underwent an ICR without covering ileostomy (one stage). Seventy-seven (20%) had undergone an ICR with end ileostomy/double-barrel ileostomy/enterocolostomy followed by closure (two stage). The median follow-up was 105 months [interquartile range (IQR) 76-136 months]. The median time to ileostomy closure was 9 months (IQR 5-12 months). There was no significant difference in surgical recurrence between the one- and two-stage groups (18% vs 16%, P = 0.94). We noted that smokers (20% vs 34%, P = 0.01) and patients with penetrating disease (28% vs 52%, P amp;lt; 0.01) were more likely to be defunctioned. A reduced recurrence rate was observed in the small high-risk group of patients who were smokers with penetrating disease behaviour treated with a two-stage strategy (0/10 vs 4/7, P = 0.12). Conclusion Despite having higher baseline risk factors, the results in terms of rate of surgical recurrence over 9 years are similar for patients having a two-stage compared with a one-stage procedure.

Place, publisher, year, edition, pages
WILEY , 2020. Vol. 22, no 4, p. 430-438
Keywords [en]
Ileocolic resection; Crohns disease; recurrence; ileostomy
National Category
Surgery
Identifiers
URN: urn:nbn:se:liu:diva-162863DOI: 10.1111/codi.14895ISI: 000501738400001PubMedID: 31715062OAI: oai:DiVA.org:liu-162863DiVA, id: diva2:1382276
Note

Funding Agencies|National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC)National Institute for Health Research (NIHR); University Hospital in Linkoping (ALF)

Available from: 2020-01-02 Created: 2020-01-02 Last updated: 2021-04-19
In thesis
1. Surgery and stomas in Crohn's disease
Open this publication in new window or tab >>Surgery and stomas in Crohn's disease
2021 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

This study investigates the evolution of abdominal surgery in treatment of Crohn´s disease (CD) in the era of immunomodulatory drugs and biologicals. It concerns risk of abdominal surgery overall and sub-categories of abdominal surgery, risk of repeat surgery and factors that affect this risk, and risk of getting a stoma. Surgical recurrence is a major clinical problem as repeat procedures are more complex and expose the patients to a higher medical risk both in conjunction with surgery and afterwards. Updated information on abdominal surgery for CD will be of use when making decisions about medical vs surgical interventions.

In a nationwide cohort of 21 273 patients with CD during the years 1990-2014, the cumulative incidence of abdominal surgery within five years of diagnosis decreased continuously down to 17.3% for patients diagnosed with CD during the last calendar period of study, 2009–2014. Ileocecal resection was the most common primary procedure. The incidence of colectomy was low in all calendar periods and continuously decreased. The incidence of proctectomy was very low even after decades with the disease, 3.0% for patients diagnosed 1990-1995 with a median follow-up of 21 years. Incidence of repeat abdominal surgery within five years of primary procedure decreased in the 90s down 16.0% in the 1996– 2000 period with a risk of ileocolic reresection of 4.4%. After 2000, despite introduction of biologicals in 1998, no further significant decrease in repeat surgery was observed.

In a retrospective review of prospectively maintained databases at three university hospitals, the rate of surgical recurrence for 389 patients with CD who had been treated with a primary ileocecal resection between 2000-2012 was investigated. The patients were operated receiving either a temporary stoma (20%) or a primary anastomosis (80%) with a median follow-up time of 105 months. Patients selected to temporary stoma had a higher prevalence of baseline risk factors usually associated with an increased risk of recurrence such as penetrating disease behaviour. Despite this, there was no difference in long-term surgical recurrence between the one- and two-stage groups; 18% vs 16%.

In a retrospective review of prospectively maintained databases at two university hospitals, the effect of smoking cessation on rate of surgical recurrence was assessed. 242 patients were included with a median follow-up of 112 months. Surgical recurrence rate for smokers vs quitters was 16/42 (38%) vs 3/31 (10%); p = 0.02; risk ratio = 3.9 despite a median time for smoking exposure after the primary procedure of three years. Among the non-smokers 28/169 (17%) had a surgical recurrence at last follow-up. 8 out of 11 smoking patients who needed a second resection went on to need a third resection. Of the patients who were free of surgical recurrence at follow-up, those who had quit smoking were significantly less likely to have been put on medical therapy compared with smokers with a risk ratio of 3.2.

In an observational study of a nationwide cohort of 19 146 patients with incident CD 2002- 2013 and followed through 2017, the incidence and prevalence of stoma was investigated. The cumulative incidence of stoma formation within five years was 2.4% and remained constant from 2002 and onwards although cumulative ever-use of biologicals increased and time to start with treatment with biologicals decreased. 48% of all stomas were reversed. Ileostomies encompassed about two-thirds of all stomas and risk of stoma was higher among patients with elderly-onset CD and among patients with perianal manifestations of the disease. 28% of the patients who underwent surgery with formation of a stoma had perianal disease. 0.6% of all incident patients had a permanent stoma five years after diagnosis.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2021. p. 88
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1768
National Category
Surgery
Identifiers
urn:nbn:se:liu:diva-172781 (URN)10.3384/diss.diva-172781 (DOI)9789179297336 (ISBN)
Public defence
2021-02-12, Online through Zoom and YouTube (contact par.myrelid@liu.se) and Belladonna, Building 511, Campus US, Linköping, 13:00 (Swedish)
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Note

Funding agency: The Research Fund from the University Hospital in Linköping – ALF

Available from: 2021-01-22 Created: 2021-01-22 Last updated: 2021-01-26Bibliographically approved

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Kalman, Thordis DisaMyrelid, Pär

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Kalman, Thordis DisaMyrelid, Pär
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Division of Surgery, Orthopedics and OncologyFaculty of Medicine and Health SciencesDepartment of Surgery in Linköping
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