Top

International Journal of Colorectal Disease

Published in:

01-02-2022 | Wound Infection | Original Article

Post-operative morbidity in Crohn’s disease: what is the impact of patient-, disease- and surgery-related factors?

Authors: G. Luglio, L. Pellegrini, A. Rispo, F. P. Tropeano, N. Imperatore, G. Pagano, A. Amendola, A. Testa, G. D. De Palma, F. Castiglione

Published in: International Journal of Colorectal Disease | Issue 2/2022

Abstract

Purpose

Over 50% of patients suffering from Crohn’s disease (CD) require surgery in their lifetime. Predictors/risk factors of post-operative morbidity and mortality in CD are poorly investigated. We aimed to assess the risk factors of post-operative morbidity/mortality in CD.

Methods

We performed a retrospective cohort study in which all CD patients operated and followed up at our tertiary Inflammatory Bowel Disease Centre from 2014 to 2019 were enrolled. For each patient, we evaluated patient-dependent, disease-dependent and surgery-dependent variables. All patients underwent small bowel and/or colic resections.

Results

Of the 165 operated patients, forty-two (25.5%) developed post-operative complications (major complication rate = 9.8%) including wound infection (12.1%), respiratory complications (4.8%), prolonged ileum (4.2%), anastomotic leak (3.6%), urinary infections (3%), abdominal abscess (2.4%), anastomotic bleeding (3.6%), abdominal bleeding (1.2%) and obstruction (0.6%). Two subjects (1.2%) required re-operation within 30 days, and one died. A surgery duration < 141 min was predictive of a better post-operative outcome (sensitivity 80.9%, specificity 43.1%, PPV 32.7%, NPV 86.9%). The multivariable analysis showed stricturing/fistulizing behaviour (OR 3.7, 95% CI 1.6–6.4, p = 0.02), need for total parenteral nutrition (OR 4.1, 95% CI 2.4–9.2, p = 0.01), pre-operative bowel cleansing (OR 0.6, 95% CI 0.41–0.83, p = 0.01) and surgery duration < 141 min (OR 0.2, 95% CI 0.08–0.7, p = 0.03) as the only risk factors associated with post-operative morbidities.

Conclusions

About 25% of CD patients develop post-operative complications. Several patient-related, disease-related and surgery-related factors should be considered risk factors for post-operative morbidity. The recognition of these factors, as well as a multidisciplinary approach to the pre-operative management of CD, could reduce post-operative complications.

Available only for authorised users

Frolkis AD, Dykeman J, Negron ME, Debruyn J, Jette N, Fiest KM et al (2013) Risk of surgery for inflammatory bowel diseases has decreased over time: a systematic review and meta-analysis of population-based studies. Gastroenterology 145:996–1006. https://doi.org/10.1053/j.gastro.2013.07.041CrossRefPubMed

Rispo A, Imperatore N, Testa A, Bucci L, Luglio G, De Palma GD et al (2018) Combined endoscopic/sonographic-based risk matrix model for predicting one-year risk of surgery: a prospective observational study of a tertiary centre severe/refractory Crohn’s disease cohort. J Crohn’s Colitis 12:784–793. https://doi.org/10.1093/ecco-jcc/jjy032CrossRef

Murthy SK, Begum J, Benchimol EI, Bernstein CN, Kaplan GG, McCurdy JD et al (2020) Introduction of anti-TNF therapy has not yielded expected declines in hospitalisation and intestinal resection rates in inflammatory bowel diseases: a population-based interrupted time series study. Gut 69:274–282. https://doi.org/10.1136/gutjnl-2019-318440CrossRefPubMed

Kopylov U, Ben-Horin S, Zmora O, Eliakim R, Katz LH (2012) Anti-tumor necrosis factor and postoperative complications in Crohn’s disease: systematic review and meta-analysis. Inflamm Bowel Dis 18:2404–2413. https://doi.org/10.1002/ibd.22954CrossRefPubMed

Brouquet A, Maggiori L, Zerbib P, Lefevre JH, Denost Q, Germain A et al (2018) Anti-TNF therapy is associated with an increased risk of postoperative morbidity after surgery for ileocolonic Crohn disease: results of a prospective nationwide cohort. Ann Surg 267:221–228. https://doi.org/10.1097/SLA.0000000000002017CrossRefPubMed

Bafford AC, Powers S, Ha C, Kruse D, Gorfine SR, Chessin DB et al (2013) Immunosuppressive therapy does not increase operative morbidity in patients with Crohn’s disease. J Clin Gastroenterol 47:491–495. https://doi.org/10.1097/MCG.0b013e3182677003CrossRefPubMed

Shah RS, Bachour S, Jia X, Holubar SD, Hull TL, Achkar J-P et al (2021) Hypoalbuminaemia not biologic exposure is associated with postoperative complications in Crohn’s disease patients undergoing ileocolic resection. J Crohn’s Colitis 15:1142–1151. https://doi.org/10.1093/ecco-jcc/jjaa268CrossRef

Dong X, Tang S, Liu W, Qi W, Ye L, Yang X et al (2020) Prognostic significance of the Controlling Nutritional Status (CONUT) score in predicting postoperative complications in patients with Crohn’s disease. Sci Rep 10:19040. https://doi.org/10.1038/s41598-020-76115-0CrossRefPubMedPubMedCentral

Abdalla S, Benoist S, Maggiori L, Zerbib P, Lefevre JH, Denost Q et al (2021) Impact of preoperative enteral nutritional support on postoperative outcome in patients with Crohn’s disease complicated by malnutrition: results of a subgroup analysis of the nationwide cohort registry from the GETAID Chirurgie group. Color Dis Off J Assoc Coloproctology Gt Britain Irel 23:1451–1462. https://doi.org/10.1111/codi.15600CrossRef

10.

Grass F, Ansell J, Petersen M, Mathis KL, Lightner AL (2019) Risk factors for 90-day readmission and return to the operating room following abdominal operations for Crohn’s disease. Surgery 166:1068–1075. https://doi.org/10.1016/j.surg.2019.08.006CrossRefPubMed

11.

Bemelman WA, Warusavitarne J, Sampietro GM, Serclova Z, Zmora O, Luglio G et al (2018) ECCO-ESCP consensus on surgery for Crohn’s disease. J Crohn’s Colitis 12:1–16. https://doi.org/10.1093/ecco-jcc/jjx061CrossRef

12.

Adamina M, Bonovas S, Raine T, Spinelli A, Warusavitarne J, Armuzzi A et al (2020) ECCO guidelines on therapeutics in Crohn’s disease: surgical treatment. J Crohn’s Colitis 14:155–168. https://doi.org/10.1093/ecco-jcc/jjz187CrossRef

13.

Pellino G, Keller DS, Sampietro GM, Angriman I, Carvello M, Celentano V et al (2020) Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn’s disease. Tech Coloproctol 24:421–448. https://doi.org/10.1007/s10151-020-02183-zCrossRefPubMed

14.

Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD et al (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250:187–196. https://doi.org/10.1097/SLA.0b013e3181b13ca2CrossRefPubMed

15.

Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213. https://doi.org/10.1097/01.sla.0000133083.54934.aeCrossRefPubMedPubMedCentral

16.

Kim NK, Senagore AJ, Luchtefeld MA, MacKeigan JM, Mazier WP, Belknap K et al (1997) Long-term outcome after ileocecal resection for Crohn’s disease. Am Surg 63:627–633PubMed

17.

Nordgren SR, Fasth SB, Oresland TO, Hultén LA (1994) Long-term follow-up in Crohn’s disease Mortality morbidity and functional status. Scand J Gastroenterol 29:1122–1128. https://doi.org/10.3109/00365529409094898CrossRefPubMed

18.

Weston LA, Roberts PL, Schoetz DJ Jr, Coller JA, Murray JJ, Rusin LC (1996) Ileocolic resection for acute presentation of Crohn’s disease of the ileum. Dis Colon Rectum 39:841–846CrossRefPubMed

19.

Graadal O, Nygaard K (1994) Crohn disease Long-term effects of surgical treatment. Tidsskr Nor Laegeforen 114:1603–1605PubMed

20.

Colombel JF, Loftus EV Jr, Tremaine WJ, Pemberton JH, Wolff BG, Young-Fadok T et al (2004) Early postoperative complications are not increased in patients with Crohn’s disease treated perioperatively with infliximab or immunosuppressive therapy. Am J Gastroenterol 99:878–883. https://doi.org/10.1111/j.1572-0241.2004.04148.xCrossRefPubMed

21.

Kunitake H, Hodin R, Shellito PC, Sands BE, Korzenik J, Bordeianou L (2008) Perioperative treatment with infliximab in patients with Crohn’s disease and ulcerative colitis is not associated with an increased rate of postoperative complications. J Gastrointest Surg 12:1730–1737. https://doi.org/10.1007/s11605-008-0630-8CrossRefPubMed

22.

Marchal L, D’Haens G, Van Assche G, Vermeire S, Noman M, Ferrante M et al (2004) The risk of post-operative complications associated with infliximab therapy for Crohn’s disease: a controlled cohort study. Aliment Pharmacol Ther 19:749–754. https://doi.org/10.1111/j.1365-2036.2004.01904.xCrossRefPubMed

23.

Aberra FN, Lewis JD, Hass D, Rombeau JL, Osborne B, Lichtenstein GR (2003) Corticosteroids and immunomodulators: postoperative infectious complication risk in inflammatory bowel disease patients. Gastroenterology 125:320–327CrossRefPubMed

24.

Sampietro GM, Colombo F, Frontali A, Baldi CM, Carmagnola S, Cassinotti A et al (2018) Totally laparoscopic multi-stage restorative proctocolectomy for inflammatory bowel diseases A prospective study on safety efficacy and long-term results. Dig Liver Dis Off J Ital Soc Gastroenterol Ital Assoc Study Liver 50:1283–1291. https://doi.org/10.1016/j.dld.2018.05.009CrossRef

25.

Subramanian V, Saxena S, Kang J-Y, Pollok RCG (2008) Preoperative steroid use and risk of postoperative complications in patients with inflammatory bowel disease undergoing abdominal surgery. Am J Gastroenterol 103:2373–2381. https://doi.org/10.1111/j.1572-0241.2008.01942.xCrossRefPubMed

26.

Hartman C, Eliakim R, Shamir R (2009) Nutritional status and nutritional therapy in inflammatory bowel diseases. World J Gastroenterol 15:2570–2578. https://doi.org/10.3748/wjg.15.2570CrossRefPubMedPubMedCentral

27.

Lochs H, Dejong C, Hammarqvist F, Hebuterne X, Leon-Sanz M, Schütz T et al (2006) ESPEN Guidelines on Enteral Nutrition: Gastroenterology. Clin Nutr 25:260–274. https://doi.org/10.1016/j.clnu.2006.01.007CrossRefPubMed

28.

Ghoneima AS, Flashman K, Dawe V, Baldwin E, Celentano V (2019) High risk of septic complications following surgery for Crohn’s disease in patients with preoperative anaemia, ypoalbuminemia and high CRP. Int J Colorectal Dis 34:2185–2188. https://doi.org/10.1007/s00384-019-03427-7CrossRefPubMed

29.

Campbell MJ, Paull NB, Thirlby RC (2013) Transverse incisions for resection of ileocolic Crohn’s disease. Am Surg 79:279–283CrossRefPubMed

30.

Aarons CB (2013) Laparoscopic surgery for Crohn disease: a brief review of the literature. Clin Colon Rectal Surg 26:122–127. https://doi.org/10.1055/s-0033-1348051CrossRefPubMedPubMedCentral

31.

Sevim Y, Akyol C, Aytac E, Baca B, Bulut O, Remzi FH (2017) Laparoscopic surgery for complex and recurrent Crohn’s disease. World J Gastrointest Endosc 9:149–152. https://doi.org/10.4253/wjge.v9.i4.149CrossRefPubMedPubMedCentral

32.

Spinelli A, Sacchi M, Bazzi P, Leone N, Danese S, Montorsi M (2012) Laparoscopic surgery for recurrent Crohn’s disease. Gastroenterol Res Pract 2012:381017. https://doi.org/10.1155/2012/381017CrossRefPubMedPubMedCentral

33.

Ponsioen CY, de Groof EJ, Eshuis EJ, Gardenbroek TJ, Bossuyt PMM, Hart A et al (2017) Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: a randomised controlled open-abel, multicentre trial. Lancet Gastroenterol Hepatol 2:785–792. https://doi.org/10.1016/S2468-1253(17)30248-0CrossRefPubMed

34.

Kono T, Ashida T, Ebisawa Y, Chisato N, Okamoto K, Katsuno H et al (2011) A new antimesenteric functional end-to-end handsewn anastomosis: surgical prevention of anastomotic recurrence in Crohn’s disease. Dis Colon Rectum 54:586–592. https://doi.org/10.1007/DCR.0b013e318208b90fCrossRefPubMed

35.

Luglio G, Rispo A, Imperatore N, Giglio MC, Amendola A, Tropeano FP et al (2020) Surgical prevention of anastomotic recurrence by excluding mesentery in Crohn’s disease: the SuPREMe-CD study - a randomized clinical trial. Ann Surg 272:210–217. https://doi.org/10.1097/SLA.0000000000003821CrossRefPubMed

36.

Luglio G, Rispo A, Castiglione F, Imperatore N, Giglio MC, De Palma GD et al (2016) Kono-type anastomosis in a patient with severe multi-recurrent Crohn’s disease. Int J Colorectal Dis 31:1565–1566. https://doi.org/10.1007/s00384-016-2567-9CrossRefPubMed

37.

Peltrini R, Greco PA, Manfreda A, Luglio G, Bucci L (2020) Kono-S anastomosis after intestinal resection for Crohn’s disease. Updates Surg 72:335–340. https://doi.org/10.1007/s13304-019-00700-wCrossRefPubMed

38.

Shimada N, Ohge H, Kono T, Sugitani A, Yano R, Watadani Y et al (2019) Surgical recurrence at anastomotic site after bowel resection in Crohn’s disease: comparison of Kono-S and end-to-end anastomosis. J Gastrointest Surg 23:312–319. https://doi.org/10.1007/s11605-018-4012-6CrossRefPubMed

39.

Cioffi I, Marra M, Imperatore N, Pagano MC, Santarpia L, Alfonsi L et al (2020) Assessment of bioelectrical phase angle as a predictor of nutritional status in patients with Crohn’s disease: a cross sectional study. Clin Nutr 39:1564–1571. https://doi.org/10.1016/j.clnu.2019.06.023CrossRefPubMed

40.

Cioffi I, Imperatore N, Di Vincenzo O, Pagano MC, Santarpia L, Pellegrini L et al (2020) Evaluation of nutritional adequacy in adult patients with Crohn’s disease: a cross-sectional study. Eur J Nutr 59:3647–3658. https://doi.org/10.1007/s00394-020-02198-0CrossRefPubMedPubMedCentral

Title: Post-operative morbidity in Crohn’s disease: what is the impact of patient-, disease- and surgery-related factors?
Authors: G. Luglio
L. Pellegrini
A. Rispo
F. P. Tropeano
N. Imperatore
G. Pagano
A. Amendola
A. Testa
G. D. De Palma
F. Castiglione
Publication date: 01-02-2022
Publisher: Springer Berlin Heidelberg
Keywords: Wound Infection
Crohn's Disease
Chronic Inflammatory Bowel Disease
Infliximab
Published in: International Journal of Colorectal Disease / Issue 2/2022
Print ISSN: 0179-1958
Electronic ISSN: 1432-1262
DOI: https://doi.org/10.1007/s00384-021-04076-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Post-operative morbidity in Crohn’s disease: what is the impact of patient-, disease- and surgery-related factors?

Abstract

Purpose

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 2/2022

Serum electrolytes, osmolality, and cleansing quality after bowel prep for colonoscopy with a PEG solution containing ascorbic acid and electrolytes

Preoperative intravenous iron treatment reduces postoperative complications and postoperative anemia in preoperatively anemic patients with colon carcinoma

Correction to: The treatment of acute appendicitis in two age‑based groups during COVID‑19 pandemic: a retrospective experience in a COVID‑19 referral hospital

The influence of intraoperative rectal washout on local recurrence of colorectal cancer following curative resection: a systematic review and meta-analysis

Risk factors for lymph node metastasis and prognosis in colorectal neuroendocrine tumours

Malignant colon polyps: predicting lymph node metastasis following endoscopic excision