Surgical Strategies to Reduce Postoperative Recurrence of Crohn's Disease After Ileocolic Resection

Postoperative recurrence after ileocaecal resection for fibrostenotic terminal ileal Crohn's disease is a significant issue for patients as it can result in symptom recurrence and requirement for further surgery. There are very few modifiable factors, aside from smoking cessation, that can reduce the risk of postoperative recurrence. Until relatively recently, the surgical technique used for resection and anastomosis had little or no impact on postoperative recurrence rates. Novel surgical techniques such as the Kono-S anastomosis and extended mesenteric excision have shown promise as ways to reduce postoperative recurrence rates. This manuscript will review and discuss the evidence regarding a range of surgical techniques and their potential role in reducing disease recurrence. Some of the techniques have been shown to be associated with significant benefits for patients and have already been integrated into the routine clinical practice of some surgeons, while other techniques remain under investigation. Current techniques such as resection of the mesentery close to the intestine and stapled side to side anastomosis are being challenged. It is looking more likely that surgeons will have a major role to play when it comes to reducing recurrence rates for patients undergoing ileocaecal resection for Crohn's disease.

The results of anterior rectal resection with the formation of a hardware anastomosis in cancer patients

Purpose of the study. A retrospective analysis of the immediate results of performing anterior rectal resections in cancer. Materials and methods. In the Department of Abdominal Oncology No. 1 with a group of X-ray vascular methods of diagnosis and treatment of the clinic of the National Medical Research Centre for Oncology of the Ministry of Health of Russia treatment for rectal cancer operations of anterior rectal resection were performed in 334 patients, while in 143 (42.8 %) cases they were low. As a standard, total mesenteric excision and lymphoid dissection in volume D2 were performed. Combined surgical interventions were performed in 68 (20.4 %) patients for locally spread tumors. As a rule, they were resection in nature and were performed with tumor infiltration of adjacent organs (bladder with ureters, ovaries, uterus, vagina, small intestine, abdominal wall). Colorectal anastomosis using crosslinking devices was formed in all cases, in 316 (94.6 %) cases it was a "side – to-end" junction, in 18 patients – "end-to-end". A preventive proximal intestinal stoma was formed in 73 (21.9 %) cases, where 67 cases it was an ileostomy, and 6 – a transversostomy. The preventive proximal intestinal stoma was not formed among 261 patients. Results. After performing anterior resections for rectal cancer operations, the complications developed in 75 (22.5 %) patients. The most threatening and dangerous complication was the failure of the colorectal anastomosis, which was noted in 12 (3.5 %) cases.This complication occurred in 8.2 % (6 patients out of 73) of preventatively stoma-treated patients, in 2.3 % of patients without a stoma (6 patients out of 261).Conclusion. The use of a preventive proximal intestinal stoma allows you to form a colorectal anastomosis even in the presence of complicated forms of rectal cancer. The number of complications directly referred to the formation of a preventive proximal intestinal stoma is relatively small, but when planning surgery for uncomplicated rectal cancer, the probability of their possible occurrence should be taken into account.

39 THE OUTCOMES OF MESENTERIC EXCISION FOR ESOPHAGEAL CANCER SURGERY

We reported the esophagus, trachea, recurrent laryngeal nerves (RLNs), and regional lymph nodes are contained in a common compartment, which we named mesotracheoesophagus. We believe complete resection of the mesotracheoesophagus is ‘mesenteric excision’ for esophageal cancer, which is the fundamental principle of intestinal cancer surgery. Since June 2011, we have performed minimal invasive esophagectomy (MIE) based on this concept. This study was aimed to evaluate outcomes of our MIE. Methods We performed a retrospective study of patients with esophageal cancer who underwent MIE at our hospital between June 2011 and March 2019. Procedure First, the dorsal side of the esophagus was dissected along a dissectable layer recognized outside the mesotracheoesophagus. After complete mobilization of the dorsal side of the esophagus, the trachea and RLNs were released from the mesotracheoesophagus and the rest of the fat tissue was dissected for radical LN dissection in the upper mediastinum. Results We identified consecutive 151 eligible patients. The median age was 68 year-old (IQR 35–83) and 117 patients were male. Tumor location was Ce:Ut:Mt:Lt:Ae = 1:12:67:58:13. Histologic cell-type was squamous cell carcinoma (SqCC):adenocarcinoma = 142:9. The clinical stage (TNM 8th edition) was I:II:III:IVa = 45:39:56:2 and I:IIB:III:IVA = 2:1:5:1 in patients with SqCC and in those with adenocarcinoma, respectively. R0 resection was performed in all patients. The Clavian-Dindo classification grade III and higher RLN paralysis rate was 7.3% and the pneumonia 5.3%. The mortality rate was 1.3%. Three-year disease free survival rate was 62.3%. Three-year overall survival rate was 71.7%. Conclusion The outcomes of mesenteric excision for esophageal cancer surgery were acceptable. Video https://www.dropbox.com/s/y1lm3uurr4t86vq/2020%20ISDE%20Abstract.mov?dl=0.

804 The Role of Kono-S Anastomosis and Mesenteric Resection in Reducing Recurrence After Surgery for Crohn’s Disease: A Systematic Review

Aim Recurrence after surgery for Crohn’s disease is common. Anastomotic configuration may influence recurrence and the mesentery may be key.The Kono-S anastomosis and radical mesenteric excision have been proposed as methods of reducing recurrence. We analysed the literature pertaining to these novel techniques. Method We searched MEDLINE, Embase and the Cochrane Library for, studies evaluating Kono-S anastomosis and/or radical mesenteric excision in Crohn’s disease. We assessed methodological quality and risk of bias using the Cochrane tool for randomized controlled trials and the JBI tool for nonrandomized trials. A narrative synthesis was used to summarize the findings. Results Nine studies (896 patients) were identified. Apart from one randomized controlled trial with a low risk of bias the overall level of evidence was poor (Grade IV). The Kono-S anastomosis was associated with a lower incidence of endoscopic and surgical recurrence (0%–3.4% vs 15%–24.4% respectively). Complications, particularly anastomotic leak rate, were also lower (1.8% vs 9.3% respectively). Evidence from a single poor-quality study suggested that mesenteric excision may reduce surgical recurrence rates compared with mesentery preservation. Conclusions The existing literature suggests that the Kono-S anastomosis is safe and may reduce endoscopic and surgical recurrence, but level of evidence is mainly poor. One element of the Kono-S technique, preservation of the mesentery, may be detrimental to recurrence. Further, higher quality, studies are required to investigate these techniques. Such studies should consider the impact of the degree of mesenteric resection in addition to the anastomosis on disease recurrence.

Surgical Treatment for Crohn's Disease: A Role of Kono-S Anastomosis in the West

More than 80% of patients with Crohn's disease (CD) will require surgical intervention during their lifetime, with high rates of anastomotic recurrence and stenosis necessitating repeat surgery. Current data show that pharmacotherapy has not significantly improved the natural history of postoperative clinical and surgical recurrence of CD. In 2003, antimesenteric hand-sewn functional end-to-end (Kono-S) anastomosis was first performed in Japan. This technique has yielded very desirable outcomes in terms of reducing the incidence of anastomotic surgical recurrence. The most recent follow-up of these patients showed that very few had developed surgical recurrence. This new approach is superior to stapled functional end-to-end anastomosis because the stumps are sutured together to create a stabilizing structure (a “supporting column”), serving as a supportive backbone of the anastomosis to help prevent distortion of the anastomotic lumen due to disease recurrence and subsequent clinical symptoms. This technique requires careful mesenteric excision for optimal preservation of the blood supply and innervation. It also results in a very wide anastomotic lumen on the antimesenteric side. The Kono-S technique has shown efficacy in preventing surgical recurrence and the potential to become the new standard of care for intestinal CD.