Benammi, Sarah

Abstract Background Proctectomy is often recommended when Crohn’s proctitis becomes refractory to medical therapy. However, some surgeons offer a temporary diverting stoma in an effort to avoid a permanent stoma. The long-term efficacy of this approach is not well-established. Our aim was to determine the long-term effectiveness of fecal diversion in patients with refractory Crohn’s proctitis. Methods This retrospective study included all patients with Crohn’s proctitis who underwent formation of a diverting ileostomy or colostomy for refractory disease from, 1998 to, 2019 in Mayo Clinic Rochester MN. Outcomes were disease recurrence, rate of stoma closure, and proctectomy. Univariate comparisons among categorical variables were performed with Pearson’s Chi-square and continuous variables using the student t-test. The cumulative probability of stoma closure was performed with a Kaplan Meier log-rank analysis. Multivariable analysis of risk factors for proctectomy and permanent stoma was achieved with logistic regression. Results Ninety-seven patients (55.7% female) were included. Ileostomy was the most common stoma type (88.7%, n=86), and colostomy was (11.3%, n=11) (Table.1). Median follow-up was, 4 years (range, 0–14). Active Crohn’s at follow-up was reported in, 68.1%. Only, 41.2% of patients underwent attempt at stoma reversal, and, 42.3% required a proctectomy (median, 19.5 months after diversion). At last follow-up, 29.9% were stoma-free, 42.3% had a new permanent stoma, and, 27.8% had the original diverting stoma (Fig.1). The multivariable predictors of proctectomy and permanent stoma were the recurrence of active CD after diversion and the need for other CD-related surgery following stoma creation (Table.2). The limitations of the study are its small sample size and its retrospective nature. The cumulative probability of stoma closure was performed with a Kaplan Meier log-rank analysis (Fig.2). Conclusion Diversion is effective at alleviating symptoms of Crohn’s proctitis in selected patients but does not significantly change disease outcome. Only a small number can avoid a long-term stoma.

Abstract Background Minimally invasive surgery (MIS) is the first-line approach for ileocolic resection in patients with Crohn’s disease (CD) and it is safe and feasible even in complex cases. However, an open approach is still required, but indications to open ileocolic resection for CD are not well described. Methods All consecutive adult patients with CD who underwent elective ileocolic resection in the Departments of Colon and Rectal Surgery at Mayo Clinic Rochester, Minnesota and Jacksonville, Florida between September 2014 and March 2021 were included and divided into “open” and “MIS” groups. Open approach was defined as upfront laparotomy, MIS included laparoscopic and robotic approaches, and conversion was defined as incision made earlier than planned. Indications to open approach were retrospectively reviewed by two authors, and any incongruity was resolved. Analogous indications were also assessed in the MIS group, as appropriate. Indications, baseline, perioperative characteristics, and short-term postoperative outcomes were compared between open and MIS. Results Among 319 ileocolic resections for CD, 45 (14.1%) were open and 274 (85.9%) MIS. Indications for open approach were severe disease, adhesions at previous surgery, history of abdominal sepsis, multifocal and extensive disease, abdominal wall involvement, concomitant open procedures, small bowel dilatation, and anaesthesiologic contraindications (Table 1). In addition, two or more of the above indications were present in 40 patients (89%) in the open group, while only in 6 patients (2%) in the MIS group (p<0.001). Compared to MIS patients, patients undergoing open ileocolic resection were older, with longer CD duration, more previous surgery and preoperative intra-abdominal abscess drainage (Table 2). Nine patients were converted in the MIS group (3.3%). Intraoperatively, open group had more adhesiolysis ≥45 min, more intraoperative complications, more blood loss, more primary stoma, less anastomosis, and longer operative time (Table 3). Postoperatively, they had more overall postoperative complications, ileus, surgical site infections, dehydration, vascular thromboembolism, higher severity by Clavien-Dindo classification, and longer length of stay (Table 4). Conclusion Overall rate of open approach ileocolic resection for CD was 14 % during a 7-years period in a referral centre. Open approach was the only operation performed in cases of abdominal wall involvement, concomitant open procedures, and anaesthesiologic contraindication. In addition, the presence of at least two indications,predicting high technical complexity, may be considered as a no-go for the MIS approach in ileocolic resections for CD.