Ileoanal pouch revision and excision surgery in a newly established pouch center: requirements and costs for service provision.

Complications of ileoanal pouch surgery affecting function and quality of life may require surgical correction or pouch excision. The management of patients with pouch dysfunction requires a multidisciplinary approach and demand for service provision include multiple healthcare professionals and resources. The aim of this study is to present the service requirements, and surgical outcomes for redo pouch surgery and pouch excision, with cost analysis of the required resources. All patients undergoing surgery for revision or excision of the ileoanal pouch from June 2021 to May 2023 were prospectively included. Patient undergoing only diagnostic procedures, or perineal procedures were excluded. Outcomes within 30 days of surgery were collected, including readmissions and re-operations. Cost analysis of all investigations, outpatient appointments and procedures prior to pouch revision or pouch excision was conducted. Twenty patients were included during the 24 months study period: 13 underwent abdominal revisional pouch surgery, 7 had ileoanal pouch excision. 15 patients (75%) were tertiary referrals from other hospitals in the UK. The median interval between index IPAA surgery and revision was 113 months. Three multidisciplinary clinical appointments, two imaging modalities, and at least one invasive day-surgery procedure were required for each patient prior to surgery. Expertise and infrastructure are needed for indication and peri-operative management of patients with pouch dysfunction requiring pouch revision or pouch excision. We estimated a starting cost of £22.605 ($29.589) for provision of pouch revision or excision surgery for investigations and treatments from referral to the pouch unit to surgery. This likely represents an underestimate as only accounts for procedures performed since referral with pouch dysfunction.

Patient-reported Outcome Measures in Ileoanal Pouch Surgery: a Systematic Review.

OBJECTIVE: To summarise frequency, type, and heterogeneity of patient-reported outcomes measures [PROMs] in papers reporting on outcomes after ileal pouch anal anastomosis [IPAA]. BACKGROUND: Prevalence of ulcerative colitis [UC] has risen in Western countries, and one in three patients requires surgery. IPAA is a frequently performed procedure for UC, and a lack of standardisation is manifest in reporting outcomes for inflammatory bowel disease [IBD] despite the clear need for inclusion of PROMs as primary outcomes in IBD trials. METHODS: Scopus, Pubmed, and Web of Science databases were searched from January 2010 to January 2023 for studies investigating outcomes in IPAA surgery. The primary outcome was the proportion of studies reporting outcomes for IPAA surgery for UC, which included PROMs. RESULTS: The search identified a total of 8028 studies which, after de-duplication and exclusion, were reduced to 79 articles assessing outcomes after IPAA surgery. In all 44 [55.7%] reported PROMs, with 23 including validated questionnaires and 21 papers using authors' questions, 22 different PROMs were identified, with bowel function as the most investigated item. The majority of studies [67/79, 85%] were retrospective, only 14/79 [18%] were prospective papers and only two were [2.5%] randomised, controlled trials. CONCLUSIONS: Only half of the papers reviewed used PROMs. The main reported item is bowel function and urogenital, social, and psychological functions are the most neglected. There is lack of standardisation for use of PROMs in IPAA. Complexity of UC and of outcomes after IPAA demands a change in clinical practice and follow-up, given how crucial PROMs are, compared with their non-routine use.

Assessment of the ileoanal pouch for the colorectal surgeon.

INTRODUCTION: Many pouch complications following ileoanal pouch surgery have an inflammatory or mechanical nature, and specialist colorectal surgeons are required to assess the anatomy of the ileoanal pouch in multiple settings. In this study, we report our stepwise clinical and endoscopic assessment of the patient with an ileoanal pouch. METHODS: The most common configuration of the ileoanal pouch is a J-pouch, and the stapled anastomosis is more frequently performed than a handsewn post-mucosectomy. A structured clinical and endoscopic assessment of the ileoanal pouch must provide information on 7 critical areas: anus and perineum, rectal cuff, pouch anal anastomosis, pouch body, blind end of the pouch, pouch inlet and pre-pouch ileum. RESULTS: We have developed a structured pro forma for step-wise assessment of the ileoanal pouch, according to 7 essential areas to be evaluated, biopsied and reported. The structured assessment of the ileoanal pouch in 102 patients allowed reporting of abnormal findings in 63 (61.7%). Strictures were diagnosed in 27 patients (26.4%), 3 pouch inlet strictures, 21 pouch anal anastomosis strictures, and 3 pre-pouch ileum strictures. Chronic, recurrent pouchitis was diagnosed in 9 patients, whilst 1 patient had Crohn's disease of the pouch. CONCLUSIONS: Detailed clinical history, assessment of symptoms and multidisciplinary input are all essential for the care of patients with an ileoanal pouch. We present a comprehensive reporting pro forma for initial clinical assessment of the patient with an ileoanal pouch, with the aim to guide further investigations and inform multidisciplinary decision-making.

Patient-reported outcome measures and surgery for Crohn's disease: systematic review.

BACKGROUND/AIMS: Crohn's disease is an inflammatory bowel disease with up to 50 per cent of patients requiring surgery within 10 years of diagnosis. Patient-reported outcome measures (PROMs) are vital to monitor and assess patient health-related quality of life (HRQoL). This systematic review aims to evaluate PROMs within studies for perioperative Crohn's disease patients. METHODS: Articles from MEDLINE, Embase, Emcare and CINAHL databases were searched to find studies relating to the assessment of HRQoL in perioperative Crohn's disease patients using PROMs and patient-reported experience measures (PREMs) from 1st January 2015 to 22nd October 2023. Bias was assessed using the ROBINS-I tool was used for non-randomized interventional studies and the Cochrane RoB2 tool was used for randomized trials. RESULTS: 1714 journal articles were filtered down to eight studies. Six studies focused on ileocaecal resection, one on perianal fistulas and one on the effects of cholecystectomy on patients with Crohn's disease. Within these articles, ten different PROM tools were identified (8 measures of HRQoL and 2 measures of functional outcome). Overall improvements in patient HRQoL pre- to postoperative for ileocaecal Crohn's disease were found in both paediatric and adult patients. Outcomes were comparable in patients in remission, with or without stoma, but were worse in patients with a stoma and active disease. CONCLUSION: There are significant variations in how PROMs are used to evaluate perioperative Crohn's disease outcomes and a need for consensus on how tools are used. Routine assessments using an internationally accepted online platform can be used to monitor patients and support areas of treatment pathways that require further support to ensure high standards of care. They also enable future statistical comparisons in quantitative reviews and meta-analyses.

Ten steps for ileoanal pouch anastomosis.

AIM: Appropriate patient selection, surgical technique, and follow-up pathways can provide optimal functional outcomes and good quality of life in many patients undergoing ileoanal pouch surgery. The aim of this study was to demonstrate the standardised approach to ileoanal pouch formation that we have developed in our pouch surgery centre. METHODS: We developed a structured approach to laparoscopic proctectomy with ileoanal pouch anastomosis formation, divided into 10 different steps. All patients referred to our centre from January 2020 to December 2022 for ulcerative colitis were included in the study. RESULTS: A total of 38 consecutive patients underwent ileal pouch-anal anastomosis (IPAA) surgery. All procedures were completed laparoscopically with one conversion to open (2.6%). A total of 13 patients had postoperative complications within 30 days of surgery (34.2%), with six (15.8%) being Clavien Dindo class 3 or higher. Median follow-up length was 18 months (range 2-30). Median number of bowel movements in 24 h at 12 months post-surgery was 4 (range 1-11). CONCLUSIONS: Our modular 10 steps approach could provide a standardised framework to surgeons in the learning curve. IPAA is a complex surgical procedure with significant postoperative morbidity. Our stepwise approach resulted in a high rate of minimally invasive surgery and could facilitate introduction of the technique.

Watchful Waiting After Radiological Guided Drainage of Intra-abdominal Abscess in Patients With Crohn's Disease Might Be Associated With Increased Rates of Stoma Construction.

Background: Management of spontaneous intra-abdominal abscess (IAA) in patients with Crohn's disease (CD) with radiologically guided percutaneous drainage (PD) was debated. Methods: This is a secondary analysis from a multicenter, retrospective cohort study of all the patients with CD who underwent PD followed by surgery at 19 international tertiary centers. Results: Seventeen patients (4.8%) who did not undergo surgery after PD were compared to those who had PD followed by surgical intervention 335/352 (95.2%). Patients who had PD without surgery were those with longer disease duration, more frequently had previous surgery for CD (laparotomies/laparoscopies), enteric fistula, on steroid treatment before and continue to have it after PD. Patients who had PD without subsequent surgical resection had a higher risk of stoma construction at later stages 8/17 (47.1%) versus 90/326 (27.6%) (P < .01). Patients with PD with no subsequent surgery had numerically higher rates of abscess recurrence 5/17 (29.4%) compared to those who had PD followed by surgery 45/335 (13.4%) the difference was not statistically significant (P = .07). Conclusions: Even with the low number of patients enrolled in this study who had PD of IAA without subsequent surgery, the findings indicate a markedly worse prognosis in terms of recurrence, length of stay, readmission, and stoma construction. Watchful waiting after PD to treat patients with spontaneous IAA might be indicated in selected patients with poor health status or poor prognostic factors.

Right Colectomy with Intracorporeal Anastomosis: A European Multicenter Propensity Score Matching Retrospective Study of Robotic Versus Laparoscopic Procedures.

BACKGROUND: This study aimed to compare the short- and long-term outcomes of robotic (RRC-IA) versus laparoscopic (LRC-IA) right colectomy with intracorporeal anastomosis using a propensity score matching (PSM) analysis based on a large European multicentric cohort of patients with nonmetastatic right colon cancer. METHODS: Elective curative-intent RRC-IA and LRC-IA performed between 2014 and 2020 were selected from the MERCY Study Group database. The two PSM-groups were compared for operative and postoperative outcomes, and survival rates. RESULTS: Initially, 596 patients were selected, including 194 RRC-IA and 402 LRC-IA patients. After PSM, 298 patients (149 per group) were compared. There was no statistically significant difference between RRC-IA and LRC-IA in terms of operative time, intraoperative complication rate, conversion to open surgery, postoperative morbidity (19.5% in RRC-IA vs. 26.8% in LRC-IA; p = 0.17), or 5-yr survival (80.5% for RRC-IA and 74.7% for LRC-IA; p = 0.94). R0 resection was obtained in all patients, and > 12 lymph nodes were harvested in 92.3% of patients, without group-related differences. RRC-IA procedures were associated with a significantly higher use of indocyanine green fluorescence than LRC-IA (36.9% vs. 14.1%; OR: 3.56; 95%CI 2.02-6.29; p < 0.0001). CONCLUSION: Within the limitation of the present analyses, there is no statistically significant difference between RRC-IA and LRC-IA performed for right colon cancer in terms of short- and long-term outcomes.

Stapled disc excision for the repair of intraoperative rectal injury during robotic surgery for deep infiltrating endometriosis.

INTRODUCTION: Intraoperative rectal perforation is an uncommon complication of pelvic surgery, which can be life-threatening and often leads to high morbidity and stoma formation rate. PURPOSE: No consensus has been reached regarding a standard of care for intraoperative iatrogenic pelvic injury. This article presents a technique for a stapled repair to completely resect a full-thickness low rectal perforation during robotic surgery for advanced endometriosis and avoid a high-risk colorectal anastomosis and the possible need for stoma formation. CONCLUSION: Stapled discoid excision is a novel and safe technique for the repair of intraoperative rectal injuries, showing multiple benefits compared to the standard colorectal resection with or without anastomosis.

Development of a specialist ileoanal pouch surgery pathway: a multidisciplinary patient-centred approach.

Background: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the gold standard procedure for ulcerative colitis refractory to medical treatment, as an alternative to permanent end ileostomy. Gaining experience in pouch surgery is difficult as the procedure is performed infrequently. This study presents an institutional initiative to promote standardisation of multidisciplinary care in IPAA surgery. Methods: A dedicated pathway for patients who had an IPAA or are considering IPAA surgery was developed among colorectal surgeons, gastroenterologists, paediatric colorectal surgeons, inflammatory bowel disease (IBD) nurses, dietitians, stoma nurses, trainees in colorectal surgery. Pathway items were discussed and finalised via emails and videoconferences.The pathway included triaging of patients referred for IPAA surgery, preoperative IBD multidisciplinary team discussion and management plan for surgery, surgical review prior to surgery, peer to peer counselling, surgical technique, postoperative short-term and long-term follow-up, audit, research and training in IPAA surgery. Results: A multidisciplinary preoperative pathway was developed and a stepwise approach to minimally invasive ileoanal pouch surgery was formalised. A dedicated one-stop ileoanal pouch clinic was established integrating endoscopy and imaging on the same day of the consultation with the surgical and gastroenterology team. The clinic reviewed 72 patients over 24 months, and during the same time 36 patients underwent IPAA surgery at our institution. Conclusions: We have described our initial experience in establishing a specialist IPAA surgery pathway and have proposed outcome measures that we hope will support a subspecialty IPAA service.

Risks Factors Associated with the Development of Crohn's Disease After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: A Systematic Review and Meta-Analysis.

BACKGROUND: Following ileal pouch-anal anastomosis [IPAA] for ulcerative colitis [UC], up to 16% of patients develop Crohn's disease of the pouch [CDP], which is a major cause of pouch failure. This systematic review and meta-analysis aimed to identify preoperative characteristics and risk factors for CDP development following IPAA. METHODS: A literature search of the MEDLINE, EMBASE, EMCare and CINAHL databases was performed for studies that reported data on predictive characteristics and outcomes of CDP development in patients who underwent IPAA for UC between January 1990 and August 2022. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. RESULTS: Seven studies with 1274 patients were included: 767 patients with a normal pouch and 507 patients with CDP. Age at UC diagnosis (weighted mean difference [WMD] -2.85; 95% confidence interval [CI] -4.39 to -1.31; p = 0.0003; I2 54%) and age at pouch surgery [WMD -3.17; 95% CI -5.27 to -1.07; p = 0.003; I2 20%) were significantly lower in patients who developed CDP compared to a normal pouch. Family history of IBD was significantly associated with CDP (odds ratio [OR] 2.43; 95% CI 1.41-4.19; p = 0.001; I2 31%], along with a history of smoking [OR 1.80; 95% CI 1.35-2.39; p < 0.0001; I2 0%]. Other factors such as sex and primary sclerosing cholangitis were found not to increase the risk of CDP. CONCLUSIONS: Age at UC diagnosis and pouch surgery, family history of IBD and previous smoking have been identified as potential risk factors for CDP post-IPAA. This has important implications towards preoperative counselling, planning surgical management and evaluating prognosis.

Conversion to Open Surgery During Minimally Invasive Right Colectomy for Cancer: Results from a Large Multinational European Study.

Background: The risk of conversion to open surgery is inevitably present during any minimally invasive colorectal surgical procedure. Conversions have been associated with adverse postoperative and oncologic outcomes. No previous study has evaluated the specific causes and consequences of conversion during a minimally invasive right colectomy (MIS-RC). Materials and Methods: We analyzed the Minimally invasivE surgery for oncologic Right ColectomY (MERCY) study database including patients who underwent laparoscopic or robotic RC because of colon cancer between 2014 and 2020. Descriptive analyses were performed to determine the different reasons for conversion. Uni- and multivariate logistic regressions were run to identify potential variables associated with this outcome. Cox regression analyses were used to evaluate the impact of conversion on tumor recurrence. Results: Over a total of 1574 MIS-RC, 120 (7.6%) were converted to open surgery. The main reasons for conversion were procedural difficulties related to adherences from previous abdominal surgical procedures (39.2%), or owing to large tumor size or infiltration of adjacent structures (26.7%). Only 16.7% of the conversions were caused by intraoperative medical or surgical complications. Converted patients required longer operative times and developed more postoperative complications, both overall (39.2% versus 27.5%; P = .006) and severe ones (13.3% versus 8.3%; P = .061). Male gender (odds ratio [OR] = 1.89 [95% confidence interval: 1.31-2.71]), obesity (OR = 1.99 [1.4-2.83]), prior abdominal surgery (OR = 1.68 [1.19-2.37]), and pT4 cancers (OR = 4.04 [2.86-5.69]) were independently associated with conversion. Conversion to open surgery was not significantly associated with tumor recurrence (hazard ratios = 1.395 [0.724-2.687]). Conclusions: Although conversion to open surgery during MIS-RC for cancer is associated with worsened postoperative outcomes, it seems not to impact on the oncologic prognosis.

Minimally Invasive Repair of Recurrent Inguinal Hernia: Multi-Institutional Retrospective Comparison of Robotic Versus Laparoscopic Surgery.

Introduction: Inguinal hernia repair is one of the most commonly performed surgical procedures in general surgery. Despite surgical advances, recurrence and chronic pain are still major issues after this intervention. Aim of our study was to retrospectively assess and compare outcomes of robotic versus laparoscopic repair of recurrent inguinal hernia. Methods: All patients who underwent recurrent inguinal hernia repair between 2014 and 2021 in five different institutions were included in our study. Baseline data on age, gender, body mass index, comorbidities, smoking habit, and anticoagulant therapy were retrospectively collected from prospectively maintained databases. Operative time, length of stay, and early and late complications were compared between the robotic and the laparoscopic approach. Results: Forty-eight patients underwent recurrent inguinal hernia repair between January 2014 and December 2021. Twenty-three patients underwent a robotic procedure, whereas 25 were submitted to the laparoscopic intervention. Overall mean follow-up was 26.2 months. There was no significant difference in the baseline characteristics of the two groups. Acceptable and comparable rates of peri- and postoperative outcomes were recorded. However, postoperative visual analog scale score and incidence of chronic pain were lower after the robotic rather than after the laparoscopic approach. (2.9 versus 3.8 P = .002; 20% versus 0%; P = .02, respectively). Conclusions: Minimally invasive repair of recurrent inguinal hernia is safe and feasible; robotic surgery is associated with low rate of postoperative and chronic pain without a significant increase in operative time.

Ileoanal pouch-related fistulae: A systematic review with meta-analysis on incidence, treatment options and outcomes.

BACKGROUND: Ileoanal pouch related fistulae (PRF) are a complication of restorative proctocolectomy often requiring repeated surgical interventions and with a high risk of long-term recurrence and pouch failure. AIMS: To assess the incidence of PRF and to report on the outcomes of available surgical treatments. METHODS: A PRISMA-compliant systematic literature search for articles reporting on PRF in patients with inflammatory bowel diseases (IBD) or familial adenomatous polyposis (FAP) from 1985 to 2020. RESULTS: 34 studies comprising 770 patients with PRF after ileal-pouch anal anastomosis (IPAA) were included. Incidence of PRF was 1.5-12%. In IBD patients Crohn's Disease (CD) was responsible for one every four pouch-vaginal fistulae (PVF) (OR 24.7; p=0.001). The overall fistula recurrence was 49.4%; procedure-specific recurrence was: repeat IPAA (OR 42.1; GRADE +); transvaginal repair (OR 52.3; GRADE ++) and transanal ileal pouch advancement flap (OR 56.9; GRADE ++). The overall failure rate was 19%: pouch excision (OR 0.20; GRADE ++); persistence of diverting stoma (OR 0.13; GRADE +) and persistent fistula (OR 0.18; GRADE +). CONCLUSION: PVFs are more frequent compared to other types of PRF and are often associated to CD; surgical treatment has a risk of 50% recurrence. Repeat IPAA is the best surgical approach with a 42.1% recurrence rate.

Influence of diabetes mellitus on inflammatory bowel disease course and treatment outcomes. A systematic review with meta-analysis.

BACKGROUND: Diabetes Mellitus (DM) may occur in IBD and influence the disease progression. AIM: To compare disease course and treatment outcomes in IBD patients with and without DM. METHODS: This is a systematic review with meta-analysis comparing patients with IBD plus DM with patients with IBD only. PRIMARY ENDPOINTS: need for surgery, IBD-related complications, hospitalizations, sepsis, mortality. Quality of life and costs were assessed. RESULTS: Five studies with 71,216 patients (49.1% with DM) were included. Risk for IBD-related complications (OR=1.12, I2 98% p = 0.77), mortality (OR=1.52, I2 98% p = 0.37) and IBD-related surgery (OR=1.20, I2 81% p = 0.26) did not differ. Risk of IBD-related hospitalizations (OR=2.52, I2 0% p < 0.00001) and sepsis (OR=1.56, I2 88% p = 0.0003) was higher in the IBD+DM group. Risk of pneumonia and urinary tract infections was higher in the IBD+DM group (OR=1.72 and OR=1.93), while risk of C. Difficile infection did not differ (OR=1.22 I2 88% p = 0.37). Mean Short Inflammatory Bowel Disease Questionnaire score was lower in the IBD+DM group (38.9 vs. 47, p = 0.03). Mean health care costs per year were $10,598.2 vs $3747.3 (p < 0.001). CONCLUSION: DM might negatively affect the course of IBD by increasing the risk of hospitalization and infections, but not IBD-related complications and mortality.

SupportiNg operAtive Photographic documentation in ileocolonic CROHN's disease surgery: The SNAPCROHN study.

BACKGROUND: There are reported variations in the intraoperative management of Crohn's disease. This consensus statement aimed to develop a standardised protocol for photographic documentation of intraoperative findings and critical procedural steps in ileocolonic Crohn's disease surgery. METHODS: Colorectal surgeons with a specialist interest in minimally invasive surgery and inflammatory bowel disease were invited as committee members to develop a survey on the use of photo-documentation in Crohn's disease surgery. A 15 item survey was developed on ethical considerations and applications of photo-documentation in audit and quality control, research, and training. RESULTS: There was strong agreement on the potential application of intraoperative photo-documentation in Crohn's disease for training, research, quality control and tertiary referrals. Reviewers agreed that intraoperative staging required photo-documentation of strictures, skip lesions, perforations, fat wrapping and mesenteric disease. The necessary steps to be photo-documented were very specific to Crohn's disease surgery, such as views of anastomosis and strictureplasties, and extent of resection(s). CONCLUSIONS: Our consensus statement identified several items for appropriate intraoperative photo-documentation in Crohn's disease surgery, to be used as an adjunct to accurate annotation of intraoperative findings and procedures.

The INTESTINE study: INtended TEmporary STomas In crohN's diseasE. Protocol for an international multicentre study.

Surgery for ileocolonic Crohn's disease can result in temporary or permanent stoma formation which can be associated with morbidity as parastomal and incisional hernias, readmissions due to obstruction or high stoma output, and have a negative impact on quality of life. We propose an international retrospective trainee-led study of the outcomes of temporary stomas in patients with Crohn's disease. We aim to evaluate both the short-term (6 month) and mid-term (18 month) outcomes of temporary stomas in patients with Crohn's Disease. Retrospective, multicentre, observational study including all patients who underwent elective or emergency surgery for ileal, colonic and ileocolonic Crohn's disease during a 4-year study period. Primary outcome is the proportion of patients who still have an ileostomy or colostomy 18 months after the initial surgery. Secondary outcomes: complications related to stoma formation and stoma reversal surgery; time interval between stoma formation and stoma reversal; risk factors for stoma formation and non-reversal of the stoma. We present the study protocol for a trainee-led, multicentre, observational study. Previous research has demonstrated significant heterogeneity surrounding the formation and the timing of reversal surgery in patients having a temporary ileostomy following colorectal cancer surgery, highlighting the need to address these same questions in Crohn's disease, which is the aim of our research.

Emergency colectomy for acute severe ulcerative colitis: a nationwide survey on technical strategies of the Italian society of colorectal surgery (SICCR).

Emergency subtotal colectomy is the standard treatment for acute severe ulcerative colitis (ASUC) unresponsive to medical treatment. No guidelines are available about surgical technique. The aim of the current survey was to identify the attitudes of Inflammatory Bowel Disease (IBD) surgeons concerning colectomy in patients with ASUC by means of a nationwide survey, with specific focus on intraoperative technical details. A survey was developed with focus on number of procedures performed, approach to vascular ligation, technique of bowel dissection, treatment of the omentum and of the rectal stump. Twenty Centres completed the survey. Seventy percent of responders started the colectomy laparoscopically. No significant differences were observed about vessels and mesocolic dissection as well as on the choice of the starting colon side and management of the omentum. Ileocolic vessels were ligated distally by 70% and at the origin by 30% and those who transect mesenteric vessels distally are significatively more likely to perform the dissection from lateral to medial and to cut the middle colic vessels distally and 100% of the ones linking left vessels at mesenteric axis transect middle colic vessels at the origin. No differences were observed in the treatment of rectal stump; however, all surgeons who performed a transrectal drainage (45%) left the rectal stump intraperitoneal (p < 0.05). No consensus exists about the technique of dissection, vascular ligation, treatment of the omentum and management of rectal stump. Further studies are needed to evaluate the impact of the different surgical techniques on patients' outcomes.

Segmental Versus Total Colectomy for Crohn's Disease in the Biologic Era: Results From The SCOTCH International, Multicentric Study.

BACKGROUND: The extent of resection in colonic Crohn's disease [cCD] is still a topic of debate, depending on the number of locations, the risk of recurrence and permanent stoma, and the role of medical therapy. METHODS: The Segmental COlecTomy for CroHn's disease [SCOTCH] international study is a retrospective analysis on six tertiary centre prospective databases, comprising all consecutive, unselected patients operated on between 2000 and 2019 with segmental colectomy [SC] or total colectomy [TC] for cCD. The primary aim was long-term surgical recurrence. Secondary aims were perioperative complications, stoma formation and predictors of recurrence. RESULTS: Among 687 patients, SC was performed in 285 [41.5%] and TC in 402 [58.5%]. Mean age at diagnosis and surgery, disease duration, and follow-up were 30 ±â€…15.8, 40.4 ±â€…15.4, 10.4 ±â€…8.6 and 7.1 ±â€…5.2 years respectively. Isolated cCD, inflammatory pattern, perianal CD, younger age, longer disease duration and preoperative maximal therapy were more frequent in TC, while SC presented more small bowel locations and perforating disease, required fewer 90-day re-admissions, and fewer temporary and definitive stomas. Morbidity and mortality were similar. The 15-year surgical recurrence was 44% in TC and 27% in SC [p = 0.006]. In patients with one to three diseased segments, recurrence risk was related to the omission of biological therapy (hazard ratio [HR] 5.6), the number of segments [HR 2.5], perianal disease [HR 1.9] and paediatric diagnosis [HR 2.8]. CONCLUSION: When technically feasible, SC is safe and reduces temporary and permanent stoma. Young age, number of locations and perianal disease adversely affect, but postoperative biological therapy significantly reduces, the long-term surgical recurrence.