A step-by-step guide to ileoanal J-pouch MRI interpretation.

BACKGROUND: Multidisciplinary management of patients with an ileoanal pouch requires dedicated imaging to identify structural problems of the pouch associated with dysfunction. The purpose of this study is to provide a framework for interpretation of magnetic resonance imaging (MRI) scan of the ileoanal pouch to enable surgeons and radiologists to work cohesively, optimise diagnosis and ultimately improve patient care. METHODS: We propose a protocol for structured MRI assessment of the ileal pouch, aiming to provide surgeons a systematic report of the anatomy, its variations and pouch complications. This guide consists of studying the characteristics of the bowel, mesentery and anal canal. RESULTS: The presented checklist is designed to systematically interpret and identify abnormalities of the ileoanal pouch on MRI. It focuses on the characteristics of the bowel (encompassing pre-pouch ileum, pouch and rectal cuff), mesentery and anal canal. The different elements of the checklist are presented in the associated supplementary video. CONCLUSIONS: A combination of clinical assessment, endoscopic evaluations and imaging is fundamental to achieving accurate diagnosis of ileoanal pouch surgery complications and pouch dysfunction.

Postoperative complications and waiting time for surgical intervention after radiologically guided drainage of intra-abdominal abscess in patients with Crohn's disease.

BACKGROUND: In patients with active Crohn's disease (CD), treatment of intra-abdominal abscess usually comprises antibiotics and radiologically guided percutaneous drainage (PD) preceding surgery. The aim of this study was to investigate the risk of postoperative complications and identify the optimal time interval for surgical intervention after PD. METHODS: A multicentre, international, retrospective cohort study was carried out. Details of patients with diagnosis of CD who underwent ultrasonography- or CT-guided PD were retrieved from hospital records using international classification of disease (ICD-10) diagnosis code for CD combined with procedure code for PD. Clinical variables were retrieved and the following outcomes were measured: 30-day postoperative overall complications, intra-abdominal septic complications, unplanned intraoperative adverse events, surgical-site infections, sepsis and pathological postoperative ileus, in addition to abscess recurrence. Patients were categorized into three groups according to the length of the interval from PD to surgery (1-14 days, 15-30 days and more than 30 days) for comparison of outcomes. RESULTS: The cohort comprised 335 CD patients with PD followed by surgery. Median age was 33 (i.q.r. 24-44) years, 152 (45.4 per cent) were females, and median disease duration was 9 (i.q.r. 3.6-15) years. Overall, the 30-day postoperative complications rate was 32.2 per cent and the mortality rate was 1.5 per cent. After adjustment for co-variables, older age (odds ratio 1.03 (95 per cent c.i. 1.01 to 1.06), P < 0.012), residual abscess after PD (odds ratio 0.374 (95 per cent c.i. 0.19 to 0.74), P < 0.014), smoking (odds ratio 1.89 (95 per cent c.i. 1.01 to 3.53), P = 0.049) and low serum albumin concentration (odds ratio 0.921 (95 per cent c.i. 0.89 to 0.96), P < 0.001) were associated with higher rates of postoperative complications. A short waiting interval, less than 2 weeks after PD, was associated with a high incidence of abscess recurrence (odds ratio 0.59 (95 per cent c.i. 0.36 to 0.96), P = 0.042). CONCLUSION: Smoking, low serum albumin concentration and older age were significantly associated with postoperative complications. An interval of at least 2 weeks after successful PD correlated with reduced risk of abscess recurrence.

Surgical management of complex ileocolonic Crohn's disease: a survey of IBD colorectal surgeons to assess variability in operative strategy.

INTRODUCTION: To explore the reported variability in the surgical management of ileocolonic Crohn' s disease and identify areas of standard practice, we present this study which aims to assess how different colorectal surgeons with a subspecialty interest in inflammatory bowel disease (IBD) surgery may act in different clinical scenarios of ileocolonic Crohn's disease. METHODS: Anonymous videos demonstrating the small bowel walkthrough and anonymised patients' clinical data, imaging and pathological findings were distributed to the surgeons using an electronic tool. Surgeons answered on operative strategy, bowel resections, management of small bowel mesentery, type of anastomosis and use of stomas. RESULTS: Eight small bowel walkthrough videos were registered and 12 assessors completed the survey with a questionnaire completion rate of 87.5%. There was 87.7% agreement in the need to perform an ileocolonic resection. However, the agreement for the need to perform associated surgical procedures such as strictureplasties or further bowel resections was only 57.4%. When an anastomosis was fashioned, the side to side configuration was the most commonly used. The preferred management of the mesentery was dissection close to the bowel. CONCLUSIONS: The decision on the main procedure to be performed had a high agreement amongst the different assessors, but the treatment of multifocal disease was highly controversial, with low agreement on the need for associated procedures to treat internal fistulae and the use of strictureplasties. At the same time, there was significant heterogeneity in the decision on when to anastomose and when to fashion an ileostomy.

Preoperative assessment of skeletal muscle mass during magnetic resonance enterography in patients with Crohn's disease.

Measurement of the psoas muscle area has been applied to estimate lean muscle mass as a surrogate marker of sarcopenia, but there is a paucity of evidence regarding the influence of sarcopenia on clinical outcomes following inflammatory bowel disease surgery. The aim of this study was to evaluate the association between MRI enterography defined sarcopenia and postoperative complications in patients undergoing elective ileocaecal resection for Crohn's disease. To obtain cross sectional area measurement of the psoas muscle, the freehand area tool was used to trace the margin of each psoas muscle at the level of L4, with the sum recorded as Total Psoas Area (TPA). The total cross sectional muscle area of the abdominal wall was recorded as Skeletal Muscle Area (SMA), while myosteatosis was measured by normalising the psoas muscle intensity with the mean intensity of the cerebrospinal fluid. The primary outcome was the incidence of 30-day postoperative complications in patients in the lowest quartile of TPA and SMA. 31 patients were included and ten patients (32.25%) developed postoperative complications within 30 days of surgery. The cut-off values for the lowest quartile for TPA were 11.93 cm2 in men and 9.77 cm2 in women, including a total of 8 patients (25.8%) with 5 patients in this group (62.5%) developing postoperative complications and 3 patients (37.5%) Clavien-Dindo class ≥ 3 complications. The cut-off values for the lowest quartile for SMA were 73.49 cm2 in men and 65.85 cm2 in women, with 4 patients out of 8 (50%) developing postoperative complications. Psoas muscle cross sectional area and skeletal mass area can be estimated on Magnetic Resonance Enterography as surrogate markers of sarcopenia with high inter-observer agreement.

Feasibility of intraoperative ultrasound of the small bowel during Crohn's disease surgery.

BACKGROUND: Intraoperative assessment of the extent and location of Crohn's disease is not standardised and relies on a mixture of surgeons' experience, tactile feedback and macroscopic appearance. To overcome this variability, we developed a protocol for full intraoperative ultrasound scan of the small bowel and we here report the results of "Assessing the Feasibility and Safety of Using Intraoperative Ultrasound in Ileocolic Crohn's Disease-The IUSS CROHN Study". METHODS: This is a prospective single centre observational study with enrolment of all patients undergoing elective surgery for terminal ileal Crohn's disease from January 2019 to March 2020. Patients underwent laparoscopic ileocolic resection, according to a standardised technique. Ultrasound intraoperative quantitative assessment was performed according to the METRIC (MREnterography or ulTRasound in Crohn's disease) scoring guide. RESULTS: Intraoperative ultrasound was successfully performed in 6 patients from the ileocaecal valve to the proximal jejunum. The median time required was 23.5 min (range 17-37 min) as compared to 6.5 min (5-12 min) required for the macroscopic evaluation performed by the surgeon. In 3 patients, intraoperative ultrasound identified more disease than surgical evaluation. CONCLUSIONS: This feasibility study demonstrated the safety of intraoperative ultrasound and allowed the development of a standardised protocol for intraoperative ultrasound and the data collection required to inform a randomised multicentre study.

Correction to: Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis.

The affiliation of the author Silvio Danese has been incorrectly published in the original publication.

Correction to: Inflammatory bowel disease (IBD) position statement of the Italian Society of Colorectal Surgery (SICCR): general principles of IBD management.

The affiliation of the author Silvio Danese has been incorrectly published in the original publication. The complete correct affiliation should read as follows.

Correction to: Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease.

The affiliation of the author Silvio Danese has been incorrectly published in the original publication.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis.

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of ulcerative colitis management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of ulcerative colitis. The committee was able to identify some points of major disagreement and suggested strategies to improve the quality of available data and acceptance of guidelines.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease.

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

Inflammatory bowel disease (IBD) position statement of the Italian Society of Colorectal Surgery (SICCR): general principles of IBD management.

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of inflammatory bowel disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the general principles of surgical treatment of inflammatory bowel disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

The Portsmouth protocol for intra-operative ultrasound of the small bowel in Crohn's disease.

AIM: Bowel preservation is paramount in Crohn's disease surgery as affected patients are typically young adults at risk of having several abdominal surgical procedures during their lifetime. Intra-operative assessment of the extent and location of Crohn's disease is not standardized and is left to a mixture of the surgeon's experience, tactile feedback, macroscopic appearance and preoperative imaging. The aim of this study was to describe the technical steps of a standardized protocol for intra-operative ultrasound assessment of the small bowel in patients undergoing surgery for ileocolic Crohn's disease. METHOD: After laparoscopic mobilization of the bowel, a periumbilical incision is performed for extracorporeal division of the mesentery and the resection and anastomosis. A gastrointestinal consultant radiologist, with expertise in Crohn's disease imaging and abdominal ultrasound, performs full intra-operative assessment of the small bowel by applying a sterile ultrasound probe directly to the bowel, prior to resection being performed by the surgeon. The bowel is assessed through the wound protector with a sterile technique and the length, location and number of segments is documented together with further quantitative assessment using the METRIC (MR enterography or ultrasound in Crohn's disease) scoring guide. RESULTS: A step-by-step protocol for intra-operative ultrasound evaluation of the entire small bowel is described. CONCLUSIONS: A standardized approach to intra-operative evaluation of the extent and location of Crohn's disease is desirable. Intra-operative ultrasound may provide added value for assessment of proximal and multifocal Crohn's disease.

Longer small bowel segments are resected in emergency surgery for ileocaecal Crohn's disease with a higher ileostomy and complication rate.

BACKGROUND: Repeated intestinal resections may have disabling consequences in patients with Crohn's disease even in the absence of short bowel syndrome. Our aim was to evaluate the length of resected small bowel in patients undergoing elective and emergency surgery for ileocolic Crohn's disease. METHODS: A prospective observational study was conducted on patients undergoing surgery for ileocolonic Crohn's disease in a single colorectal centre from May 2010 to April 2018. The following patients were included: (1) patients with first presentation of ileocaecal Crohn's disease undergoing elective surgery; (2) patients with ileocaecal Crohn's disease undergoing emergency surgery; (3) patients with recurrent Crohn's disease of the distal ileum undergoing elective surgery. The primary outcomes were length of resected small bowel and the ileostomy rate. Operating time, complications and readmissions within 30 days were the secondary outcomes. RESULTS: One hundred and sixty-eight patients were included: 87 patients in the elective primary surgery group, 50 patients in the emergency surgery group and 31 in the elective redo surgery group. Eleven patients (22%) in the emergency surgery group had an ileostomy compared to 10 (11.5%) in the elective surgery group (p < 0.0001). In the emergency surgery group the median length of the resected small bowel was 10 cm longer than into the group having elective surgery for primary Crohn's disease. CONCLUSIONS: Patients undergoing emergency surgery for Crohn's disease have a higher rate of stoma formation and 30-day complications. Laparoscopic surgery in the emergency setting has a higher conversion rate and involves resection of longer segments of small bowel.

Ex vivo model for a new bilateral antimesenteric V-modified side-to-side isoperistaltic anastomosis to prevent recurrence in ileocolic Crohn's disease.

INTRODUCTION: The high rate of recurrence following ileocaecal resection for Crohn's disease may lead to repeat surgery in 20-30% of patients at five years after surgery. Recurrence usually occurs at the anastomosis and the neoterminal ileum and the association of a strictureplasty to widen the bowel lumen in the regions immediately proximal ('anastomotic inlet') and distal ('anastomotic outlet') to the anastomosis may delay or reduce the risk of surgical recurrence. MATERIALS AND METHODS: A side to side isoperistaltic anastomosis, with an associated V-modified strictureplasty on the anti-mesenteric border at the level of the anastomosis inlet and outlet has been designed. We produced a wet lab ex vivo model of the anastomosis and, to evaluate the different calibre of the anastomotic segments, we compared it with ex vivo models of three anastomotic configurations currently used in surgery for Crohn's disease: i) side to side isoperistaltic anastomosis; ii) modified side-to-side isoperistaltic anastomosis with double Heineke-Mikulicz procedure (Sasaki anastomosis); iii) anti-mesenteric functional end-to-end handsewn anastomosis (Kono-S anastomosis). RESULTS: Differences were recorded at the level of the anastomosis inlet and outlet, with a larger volume estimated in the Sasaki anastomosis and in the V-modified anastomosis. The V-modified anastomosis had a larger volume compared with the Sasaki anastomosis for a longer segment of small bowel. CONCLUSIONS: We have developed an experimental animal model for a new anastomotic technique which could be applied in surgery for Crohn's disease following small-bowel or ileocolic resection.

Laparoscopic Redo Ileocolic Resection for Crohn's Disease in Patients with Previous Multiple Laparotomies.

PURPOSES:: Over 80% of patients with primary ileocolic Crohn's disease have a surgical resection within 10 years of diagnosis, and 40%-50% of them need further surgery within 15 years. Laparoscopic surgery can be challenging due to a thickened mesentery and the potential for fistulas, abscesses, and phlegmons. Aim of this study is to analyze the short-term outcomes of laparoscopic redo ileocolic resections for Crohn's disease in patients with previous multiple laparotomies. METHODS:: All patients undergoing laparoscopic surgery for ileocolic Crohn's disease from March 2006 to February 2017 were prospectively evaluated. Short term outcomes of laparoscopic ileocolic resection were compared between patients with previous multiple major surgeries and recurrent Crohn's disease, and patients undergoing surgery for the first presentation of Crohn's disease and no history of previous surgery. Conversion rate and 30-day morbidity were the primary outcomes. Reoperations, readmissions, operating time and length of stay were the secondary outcomes. RESULTS:: 29 patients with recurrent Crohn's disease and previous multiple laparotomies were included: the number of laparotomies these patients previously underwent was 2 in 19 cases (65.5%), 3 in 9 (31%), and 4 in 1 (3.5%). In total, 90 patients with no history of any previous abdominal surgery, who underwent laparoscopic ileocecal resection for Crohn's disease, represented the control group. No differences were found in morbidity and conversion rate. Operating time was longer in patients with history of previous abdominal surgery. CONCLUSION:: Laparoscopic redo ileocolic resection for Crohn's disease is feasible and safe in patients with previous multiple laparotomies at the expense of longer operating time.