Positive Histological Inflammatory Margins Are Associated With Increased Risk for Intra-abdominal Septic Complications in Patients Undergoing Ileocolic Resection for Crohn's Disease

1Department of Surgery, Tel-Aviv Medical Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel 2Department of Surgery B, Meir Medical Center, Kfar-Saba, and the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.
Diseases of the Colon & Rectum (Impact Factor: 3.75). 11/2012; 55(11):1125-30. DOI: 10.1097/DCR.0b013e318267c74c
Source: PubMed


: Rates of postoperative complications are particularly high among patients with Crohn's disease.
: The aim of this study was to assess whether positive inflammatory histological margins, among other factors, pose a risk for intra-abdominal septic complications in patients with Crohn's disease undergoing ileocolic resection.
: A retrospective study of patient records, during 2000-2010, was conducted.
: This investigation was performed at a single medical center.
: Included were 166 individuals with Crohn's disease (85 males, mean age 35.6).
: Ileocolic resection with primary anastomosis was performed.
: The primary outcomes measured were postoperative intra-abdominal septic complications.
: Twenty-five patients (15%) developed intra-abdominal septic complications, including anastomotic leak, intra-abdominal abscesses and collections, and enterocutaneous fistulas. There were no postoperative deaths. Univariate analysis revealed that a long course of disease before surgery, an emergency surgery, steroid treatment of more than 3 months before surgery, additional sigmoidectomy, and positive surgical margins detected on histopathological examination were associated with intra-abdominal septic complications. In a multivariate analysis, only disease duration longer than 10 years (OR 4.575 (CI 1.592-13.142), p = 0.005), additional sigmoidectomy (OR 5.768 (CI 1.088-30.568), p = 0.04), and positive histological resection margins (OR 2.996 (CI 1.085-8.277), p = 0.03) were found to be independent risk factors.
: This study was limited by the incomplete data regarding preoperative albumin levels.
: Positive histological margins, disease duration of more than 10 years, and added sigmoidectomy are independent risk factors that are associated with postoperative intra-abdominal septic complications in patients undergoing ileocolic resection for Crohn's disease. These risk factors should be considered when the need for a diverting stoma is questionable. A frozen section of the margins may assist in the decision as to a temporary ileostomy construction.

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    ABSTRACT: There is conflicting evidence on the effects of thiopurines (azathioprine or mercaptopurine) and anti-tumor necrosis factor (TNF) therapies on rates of surgery among patients with Crohn's disease (CD). We aimed to identify factors that identify patients not likely to respond to medical therapy who will therefore require surgery. We performed a retrospective study, using the Alberta Inflammatory Bowel Disease Consortium registry to identify 425 patients diagnosed with CD who received a prescription of a thiopurine and/or anti-TNF agent from a referral center, from July 1, 1975 through September 13, 2012.We collected data on CD-related abdominal surgery following therapy and disease features when therapy was instituted. Cox proportional regression models were used to associate disease features with outcomes after adjusting for potential confounders. Risk estimates were presented as hazard rate ratios (HR) with 95% confidence intervals (CI). Among patients given thiopurines, stricturing disease (adjusted HR, 4.63; 95% CI, 2.00-10.71), ileal location (adjusted HR, 6.20; 95% CI, 1.64-23.42), and ileocolonic location (adjusted HR, 3.71; 95% CI, 1.08-12.74) at the time of prescription were significantly associated with surgery. Prescription of an anti-TNF agent after prescription of a thiopurine reduced risk the risk for surgery, compared with patients prescribed only a thiopurine (adjusted HR, 0.41; 95% CI, 0.22-0.75). Among patients given anti-TNF agents, stricturing (adjusted HR, 6.17; 95% CI, 2.81-13.54) and penetrating disease (adjusted HR, 3.39; 95% CI, 1.45-7.92) at the time of prescription were significantly associated with surgery. Older age at diagnosis (17-40 y) reduced the risk for abdominal surgery (adjusted HR, 0.41; 95% CI, 0.21-0.80) compared with a younger age group (≤16 y). Surgery before drug prescription reduced the risk for further surgeries among patients who received thiopurines (adjusted HR, 0.33; 95% CI, 0.13-0.68) or anti-TNF agents (adjusted HR, 0.49; 95% CI, 0.25-0.96). Terminal ileal disease location was not associated with a stricturing phenotype. Based on a retrospective database analysis, patients prescribed thiopurine or anti-TNF therapy when they have a complicated stage of CD are more likely to require surgery. Better patient outcomes are achieved by treating CD at early inflammation stages; delayed treatment increases rates of treatment failure.
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