On behalf of the American Society of Colon and Rectal Surgeons, Clinical Practice Guidelines Committee Funding/Support: None reported. Financial Disclosure: None reported.
The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient. STATEMENT OF THE PROBLEM Crohn's disease (CD) is an idiopathic, incurable chronic inflammatory disease of the GI tract, which affects over one million people in the United States and continues to increase in incidence for unknown reasons.1 The characteristic transmural inflammation of CD can occur anywhere along the GI tract, resulting in an inflammatory, fibrostenotic, or penetrating phenotype. Although the degree of symptoms is variable and may wax and wane throughout the disease course, patients can require chronic immunosuppression and operations to treat the disease symptoms, but both are unable to cure the disease. Monoclonal antibodies have become the cornerstone of medical therapy for moderate-to-severe disease; however, their utility is limited by primary and secondary loss of response and the risk of serious opportunistic infection with anti-tumor necrosis factor (TNF) medication.2–9 Although the rate of surgical intervention for medically refractory disease has decreased over the past 6 decades and less emergent surgery is being performed, a meta-analysis of population-based studies reported that rates of surgical intervention for medically refractory disease remain high at 16%, 33%, and 47% at 1, 3, and 5 years from diagnosis.10,11 After resection, because surgery is not curative, 70% to 90% of patients will have endoscopic recurrence by 1 year and up to 35% of patients will have a repeat intestinal resection within 10 years.12–14 Given the typical complexity of patients with CD requiring surgical intervention, multidisciplinary care with gastroenterologists, surgeons, radiologists, pathologists, and other ancillary team members is critical for optimizing patient care. Because the management of patients with CD involves different medical disciplines working in conjunction with one another, these guidelines must be viewed in that context and represent only a portion of the treatment necessary for the optimal care of these patients. This clinical practice guideline will focus on the surgical management of patients with CD. METHODOLOGY This clinical practice guideline is based on the previous ASCRS Clinical Practice Guideline for the Surgical Management of Crohn's Disease that was published in 2015.15 Bowel preparation, enhanced recovery pathways, prevention of thromboembolic disease, and the management of perianal disease, although relevant to the management of patients with CD, are beyond the scope of this guideline and are addressed in other ASCRS clinical practice guidelines.16–19 An organized search of MEDLINE, PubMed, EMBASE, Scopus, and the Cochrane Database of Collected Reviews limited to the English language was performed from January 1, 2014 through December 1, 2019. The complete search strategy is listed in Supplemental Digital Content, https://links.lww.com/DCR/B243. Keyword combinations included "Crohn's disease"; "colitis"; "ileitis"; "fibrostenotic"; "stricture"; "abscess"; "phlegmon"; "fistula"; "megacolon"; "fulminant"; "complications"; "infliximab"; "steroids"; "TNF"; "tumor necrosis factor'; "immunomodulators"; "Crohn abscess"; "Crohn anastomosis"; "Crohn cancer"; "Crohn colitis"; "Crohn dilation"; "Crohn dysplasia"; "Crohn endoscopy"; "Crohn laparoscopy"; "Crohn laparotomy"; "Crohn operation"; "Crohn resection"; "Crohn stricture"; "Crohn strictureplasty"; and "Crohn surgery" or "laparoscopic approach*" or "laparoscopic resection*" or "minimally invasive approach*" or "minimally invasive surgery*" or "pouch*" or "pouch failure*" or "pouch outcome*" or "robotic platform*" or "robotic resection*" or "robotics*" or "stoma*" or "stomas*" or "use of diversion.*" In brief, a total of 15,643 unique journal titles were identified including 142 articles from a directed search of references embedded in candidate publications including references from the 2015 guideline. The initial review of the search results titles led to the exclusion of 14,562 articles. After a review of the remaining 1081 articles, a total of 312 articles were chosen for grading of the recommendations (Fig. 1). Emphasis was placed on prospective trials, meta-analyses, systematic reviews, and practice guidelines. Peer-reviewed observational studies and retrospective studies were included when higher-quality evidence was insufficient. The final source material used was evaluated for the methodologic quality, the evidence base was examined, and a treatment guideline was formulated by the subcommittee for this guideline. The final grade of recommendation and level of evidence for each statement were determined using the Grades of Recommendation, Assessment, Development, and Evaluation system (Table 1).20,21 When agreement was incomplete regarding the evidence base or treatment guideline, consensus from the committee chair, vice chair, and 2 assigned reviewers determined the outcome. Members of the ASCRS Clinical Practice Guidelines Committee worked in joint production of these guidelines from inception to final publication. Recommendations formulated by the subcommittee were reviewed by the entire Clinical Practice Guidelines Committee, selected members of the ASCRS Inflammatory Bowel Disease committee, and selected practicing gastroenterologists. The guideline was peer reviewed by Diseases of the Colon & Rectum and the final guideline was approved by the ASCRS Executive Council. In general, each ASCRS Clinical Practice Guideline is updated every 5 years. No funding was received for preparing this guideline and the authors have declared no competing interests related this material. This guideline conforms to the Appraisal of Guidelines Research and Evaluation (AGREE) checklist.TABLE 1.: The GRADE System: grading recommendationsFIGURE 1.: PRISMA literature search flow sheet.OPERATIVE INDICATIONS Medically Refractory Disease 1. Patients who demonstrate an inadequate response to, develop complications from, or are nonadherent with medical therapy should typically be considered for surgery. Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. The goals of medical treatment of CD are to achieve remission with endoscopic mucosal healing in patients with active disease and avoid relapse in those with quiescent disease. When glucocorticoids are used, clinical improvement is usually evident within days of initiating intravenous therapy and within 2 to 4 weeks of treatment with oral glucocorticoids. When immunomodulators (eg, 6-mercaptopurine, methotrexate, azathioprine) are used as a monotherapy, a plateau in improvement of clinical symptoms is often demonstrated within 12 to 16 weeks.14 On the initiation of monoclonal antibody therapy with an anti-TNF (eg, infliximab, adalimumab, certolizumab pegol), anti-integrin (eg, vedolizumab), or anti-interleukin (eg, ustekinumab) a 6- to 12-week course of therapy is usually recommended to assess efficacy.22 An exception to these timelines is in the setting of severe, acute colitis, when infliximab is given as a loading dose in an attempt to control the acute presentation; in this situation, a more limited period of about 5 to 7 days is usually recommended to determine the initial response justifying continuation of therapy.23–25 Surgical intervention may be warranted in patients who are unable to tolerate medical therapy because of side effects, are nonadherent to medical therapy, or have medically refractory disease activity due to primary or secondary loss of response.26–29 Surgery may also be considered in patients who are steroid dependent regardless of disease severity because of the deleterious effects of chronic glucocorticoid use.30 A recent randomized, controlled trial also proposed laparoscopic resection as a reasonable option rather than initiating monoclonal antibody therapy in the setting of otherwise refractory, relatively limited disease (eg, short-length <40 cm, inflammatory, nonstricturing, ileocolic disease).31 Inflammation 1. Patients with severe acute colitis who do not adequately respond to medical therapy or who have signs or symptoms of impending or actual perforation should undergo surgery. Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. Because of the limited evidence specific to CD, the management of severe, acute colitis in patients with CD is based almost entirely on our understanding of this condition in patients with ulcerative colitis (UC).32,33 A recent prospective cohort comparative analysis showed that the severe forms of UC and Crohn's colitis respond similarly to medical therapy with a response to steroids in 73% and 68% of patients and to anti-TNF drugs in 89% and 86% of patients.33 "Severe acute colitis" and "fulminant colitis" are terms that apply to patients with colitis, frequent stools (≥6/day), and systemic inflammatory response syndrome (SIRS).32,34 The degree of severity can be classified as mild, moderate, or severe using the modified Truelove and Witts criteria, with severe colitis defined as ≥6 bowel movements per day and at least one of the following: temperature >37.8°C, pulse >90 beats per minute, erythrocyte sedimentation rate >30 mm/h, C-reactive protein >30 mg/L, or a hemoglobin <10.5 g/dL.34 "Megacolon" is often defined as transverse colon diameter ≥5.5 cm and, in the setting of SIRS, is termed "toxic megacolon."35,36 When severe Crohn's colitis is suspected, alternative causes of colitis (eg, Clostridium difficile, cytomegalovirus) should typically be excluded with stool studies and endoscopic mucosal biopsy via careful flexible sigmoidoscopy, and therapeutic drug monitoring may be helpful to guide monoclonal antibody therapy.37–40 Laboratory testing including serum C-reactive protein, hemoglobin, creatinine, and albumin levels, fecal calprotectin and monoclonal antibody drug levels for therapeutic drug monitoring can help measure the response to therapeutic interventions.40,41 Given the potentially masking effects of high-dose steroids, patients are usually followed with plain abdominal x-rays to determine the presence of megacolon or bowel perforation, and these may need to be repeated often, if not daily, until patients' overall clinical condition improves. Initial treatment of severe colitis includes supportive care, intravenous fluid resuscitation, avoidance of antidiarrheal medication, limited use of opiates and anticholinergics, and prompt initiation of intravenous glucocorticoids (eg, methylprednisolone 60 mg/day). Venous thromboembolism prophylaxis beginning on hospital admission is recommended because active colitis is a risk factor for this potentially life-threatening condition, whereas bowel rest and prophylactic antibiotics are usually not necessary.40,42,43 In general, a response to steroid therapy includes improvement or resolution of the SIRS, a decrease in stool frequency (eg, <6/day), and overall clinical improvement. When patients do not respond adequately within about 72 hours, using a second-line therapy such as an anti-TNF drug or cyclosporine should typically be considered.24,25,44,45 A response to anti-TNF or cyclosporine in this setting should occur typically within about 5 to 7 days.46–48 For medical treatment failures or colitis-related emergencies (eg, colon perforation), subtotal colectomy with end ileostomy is generally recommended.49 Stricture 1. Endoscopic dilation may be considered for patients with short-segment, noninflammatory, symptomatic small-bowel or anastomotic strictures. Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. Strictures complicating CD can arise anywhere along the intestinal tract and are often classified as either inflammatory or fibrostenotic in nature. The degree of inflammation surrounding the bowel wall can be suggestive of an inflammatory stricture, and chronic upstream bowel dilation is more typical of a fibrostenotic stricture. However, these categories are not mutually exclusive because intestinal fibrosis is a dynamic process and inflammation and fibrosis can coexist within the same stricture or region.50,51 Ultrasound, computed tomography enterography (CTE) and magnetic resonance enterography (MRE) can diagnose small-bowel strictures with a high level of accuracy, and recent guidelines report algorithms for trying to distinguish between fibrotic and inflammatory strictures.52–54 Magnetic resonance imaging avoids the radiation exposure from CT imaging that may be a particularly relevant consideration in younger patients who potentially face an increased lifetime cumulative radiation exposure.55 In addition, MRE may be better than CTE in distinguishing inflammatory, fibrotic, and mixed inflammatory/fibrotic strictures.53 However, obtaining an MRE after a CTE has been performed is not usually recommended because of the lack of additional diagnostic yield under these circumstances.56 Medical therapy with steroids, immunomodulators, or anti-TNF drugs remains the first-line treatment for strictures with an inflammatory component, whereas endoscopic or surgical therapy is usually indicated for fibrostenotic strictures.51,57 The typical indication for endoscopic therapy is a limited, short-segment (<5 cm) stricture in the absence of associated penetrating disease (eg, abscess, fistula). Primary and anastomotic strictures may be successfully dilated with endoscopic techniques.58,59 The most commonly used dilation approach is a "through-the-scope" method using variable diameter dilating balloons, although a standardized methodology of sequential dilations has not been established.60 The technical success of endoscopic stricture dilation is about 90%, and complications (eg, perforation, hemorrhage) occur in 2% to 4% of cases.53,58,59,61,62 After successful dilation of a nonanastomotic site (eg, primary stricture), repeat endoscopic dilation is required in 41% to 73% of patients followed for up to 5 years, and recurrence rates are higher at anastomotic sites in comparison to nonanastomotic sites.54,59,60,63 Dilation of strictures <5 cm in length in the setting of CD has been associated with the best long-term outcome.58,59 Steroid injection of the stricture during dilation is typically not helpful.59,63,64 Within 2 to 5 years after endoscopic dilation of primary or anastomotic strictures, surgical intervention is required in about one-third of patients.53,58,59,63 2. Surgery is indicated for patients with symptomatic small-bowel or anastomotic strictures that are not amenable to medical therapy and/or endoscopic dilation. Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. Resection or strictureplasty is warranted for small-bowel and anastomotic strictures when medical and/or endoscopic treatments are unsuccessful or when a stricture is believed to be fixed and fibrotic in nature and not amenable to medical therapy.65 When resection is performed, the extent of resection should typically include only about 2 cm of grossly uninflamed bowel proximal and distal to the diseased segment, because there is no benefit to obtaining microscopically negative margins or removing extended lengths of normal bowel.66–68 Although limited mesenteric excision remains the most common practice under these circumstances, the role of a more extensive mesenteric resection is being investigated and is reviewed later.69 Sutured or stapled techniques, both suitable for bowel anastomosis in this setting, and the use of a defunctioning ileostomy are discussed elsewhere in this guideline.70–72 Strictureplasty, an alternative to resection, is used in general to preserve bowel length and is often the preferred option for patients with multiple strictures separated by relatively longer segments of grossly normal small bowel, in particular, in patients who are at risk for short-bowel syndrome. Strictureplasty may also be particularly suitable for selected duodenal strictures where resection carries higher risk, but should typically be avoided in the setting of perforation, inflammatory mass, malignancy, dysplasia, or severe malnutrition.73–75 In 38% to 71% of cases, strictureplasty is combined with bowel resection to address multifocal disease while maximizing bowel preservation.76,77 The type of strictureplasty performed is largely based on the length of the stricture and the pliability of the affected bowel. In general, Heineke-Mikulicz strictureplasty is used for strictures <10 cm, Finney strictureplasty can address strictures 10 to 25 cm in length, and isoperistaltic side-to-side strictureplasty is indicated for strictures longer than about 25 cm.75,78–80 Complications of strictureplasty have been reported in 4% to 18% of patients in large series and include surgical site infection, obstruction, stricture-site hemorrhage, sepsis, perforation, and, in 6% of patients, early reoperation.76,78,81–83 Low preoperative albumin, weight loss, advanced age, preoperative steroid use, and abscess or fistula at the time of strictureplasty are risk factors for intra-abdominal septic complications.82,84 Patients undergoing strictureplasty are at a risk for recurrence, which, in general, is comparable to patients undergoing resection.85 Studies report a 5-year recurrence rate after strictureplasty in jejunoileal and ileocolic locations of 25% to 30% that includes a roughly 3% site-specific recurrence rate; the remaining majority of recurrences develop in intestinal segments remote from original strictureplasty sites.81,82 After strictureplasty, reoperation for recurrent disease has been reported in 29%, 34%, and 73% of patients after 5, 7.5, and 10 years.76,82 3. Patients with strictures of the colon that cannot be adequately surveyed endoscopically should be considered for resection. Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. Colonic strictures occur in 9% to 13% of patients with CD and are most commonly found at a single site, although multiple strictures may be present.86–88 Endoscopic dilation can be used in colonic strictures to alleviate symptoms with success rates similar to those seen after dilating small-bowel strictures.62 It is important to appreciate that 2% to 6% of colonic CD strictures contain occult dysplasia or cancer, but it is often difficult to differentiate malignant from benign strictures by using clinical criteria alone. Factors more commonly associated with cancer include shorter segment strictures, advanced patient age, longer duration of disease, and absence of active colitis.87–89 Colorectal strictures should be assessed with multiple endoscopic biopsies and cytological brushings, if needed, to evaluate for malignancy.90 If a stricture cannot be adequately surveyed to exclude a concomitant carcinoma, resection following standard oncologic principles should typically be performed. Although colonic strictureplasty has been reported, this is generally discouraged due to a lack of proven benefit as well as concerns about potential carcinoma being left in situ.91 Penetrating Disease 1. Patients with a free perforation should undergo surgical resection of the perforated segment. Grade of recommendation: Strong recommendation based on moderate-quality evidence, 1B. Free perforation of the bowel in patients with CD is uncommon with a reported incidence of 1.5% to 16% with nearly all cases involving a solitary perforation of the small bowel.92–97 Resection of the perforated segment is preferred over simple suture closure because of the relatively high failure rate and increased risk of morbidity associated with primary repair.93,98 2. Patients with penetrating Crohn's disease with abscess formation may be managed with antibiotics with or without drainage followed by interval elective resection or medical therapy depending on the clinical situation and patient preferences. Grade of recommendation: Weak recommendation based on moderate-quality evidence, 2B. Intra-abdominal abscesses in patients with CD typically result from a penetrating disease phenotype with an associated distal stricture and can have an associated inflammatory process that affects other segments of bowel walling off the abscess. Although smaller abscesses (<3 cm) can generally be treated with antibiotics alone, larger abscesses are typically treated with antibiotics and percutaneous drainage (PD) that has a low rate of enterocutaneous fistula formation.99–105 Comparative studies and meta-analyses comparing PD and initial surgery for spontaneous abdominal abscess in patients with CD indicate that successful PD, defined as abscess resolution and avoidance of subsequent surgery, occurs in 23% to 78% of patients; abscess recurrence is significantly higher after PD alone versus surgical intervention (OR, 2.16; 95% CI, 1.03–4.54; p = 0.04).106–111 Factors associated with PD failure include concomitant steroid use, colonic disease, and abscesses that are large, multiloculated, or multifocal.107,112,113 Percutaneous drainage used as a bridge to bowel resection compared with bowel resection without prior PD results in decreased overall complications, need for diverting stoma, and overall cost, and no difference in rates of postoperative enterocutaneous fistula and anastomotic leak.107,109,114 Preoperative PD combined with antibiotics typically improves postoperative outcomes and shortens the overall length of stay.115–117 In a meta-analysis of 513 patients who have CD with spontaneous abscess, the postoperative complication rate was significantly lower in patients who underwent PD followed by surgical intervention versus surgical intervention at presentation (OR, 0.44; 95% CI, 0.23–0.83; p = 0.03).109 Resection under these circumstances should emphasize bowel preservation and avoid overaggressive resection, because the removal of bowel can lead to immediate or future development of short-bowel syndrome.103 Anti-TNF therapy in the setting of an inflammatory mass (ie, phlegmon) with a concomitant abscess typically carries a low risk when initiated after intravenous antibiotics and PD of the abscess, as needed.118 Although conflicting studies have been published, the treatment strategy of drainage followed by anti-TNF therapy may prevent bowel resection in up to 30% of patients.111 3. Patients with enteric fistulas that persist despite appropriate medical therapy should be considered for surgery. Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. In the setting of penetrating disease with enteric fistulas, concomitant abscesses should be identified and drained when feasible.119 The inability to control intra-abdominal consequences of a penetrating phenotype (ie, abscess, phlegmon) usually warrants resection of the diseased bowel.120 In a multicenter, retrospective study of 93 patients with intra-abdominal fistulizing CD (enteroenteric/colic 77%, enterovesicle 17%, enterovaginal 6%), 59% had a coexisting stricture, but none had a coexistent abscess; all patients were treated primarily with anti-TNF therapy with or without a concomitant immunomodulator, and surgery was eventually performed in 44% of patients.121 In this study, the cumulative surgery rate was 18%, 27%, 37%, and 47% at 1, 2, 3, and 5 years from the induction of anti-TNF agents, and did not differ by fistula location; thus, surgery was avoided in over 50% of patients. A lower Crohn's Disease Activity Index122 and shorter interval between the diagnosis of fistula and starting the monoclonal antibody were independently and significantly associated with lower risk of undergoing surgery. In other multicenter retrospective studies and systematic reviews of patients with enterovesicular fistulas, anti-TNF therapy has been shown to result in a complete and durable response in 45% to 57% of patients.123,124 When operative treatment is required, management requires differentiating diseased bowel from other loops of bowel or organs that are secondarily involved that may or may not require resection. In general, diseased bowel is resected, whereas noninflamed bowel can be primarily repaired and other internal organs (eg, bladder, vagina) can be repaired or left to heal by secondary intention, depending on the circumstances.125–129 Of note, the mere presence of a fistula does not necessarily mandate surgery, especially in the absence of malabsorption, intractable diarrhea, or recurrent infection.116 Hemorrhage 1. Stable patients with gastrointestinal hemorrhage may be evaluated and treated by endoscopic and/or interventional radiologic techniques. Unstable patients, despite resuscitation efforts, should typically undergo operative exploration. Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. Acute lower GI hemorrhage is an unusual complication of CD, occurring in 0.9% to 10% of patients with an incidence that correlates with disease duration.130–135 Significant lower GI bleeding in patients with CD is more often secondary to severe inflammation and, unlike other more common sources of massive lower GI bleeding (eg, diverticula, arteriovenous malformation), rarely necessitates the diagnostic journey required in a bleed of unknown origin. Patients with significant bleeding should undergo concomitant resuscitation along with appropriate diagnostic measures, which, in stable patients, may include CT angiography, endoscopy, nuclear scintigraphy, and/or conventional mesenteric arteriography.136 Although not specific to CD, CT angiography in the setting of acute GI bleeding has sensitivity rates up to 89% and specificity rates up to 92%.136–138 The likelihood of identifying a precise bleeding source is somewhat limited, because spontaneous cessation of bleeding occurs in nearly one-half of all patients with lower GI bleeding; however, recurrent bleeding occurs in nearly 40% of cases.129,133 More specific to patients with CD, endoscopic clipping may be difficult in the presence of inflamed and friable mucosa and rebleeding in patients successfully managed with nonoperative measures may be reduced with anti-TNF therapy.130,133 In general, surgical treatment is recommended in patients with CD with life-threatening bleeding, persistent hemodynamic instability, or recurrent, significant GI bleeding following nonoperative measures. Although mortality related to surgical management is high (up to 7%), rates of rebleeding are much lower compared with nonsurgical intervention (6% versus 39%).130,139 The primary challenges with surgical intervention are accurately identifying the bleeding site and effectively managing the risk of short-bowel syndrome with every additional segment of bowel removed, recognizing that two-thirds of patients with CD who bleed have otherwise quiescent disease.130 Therefore, if the source of bleeding has been localized by using preoperative or intraoperative modalities, a targeted resection is typically recommended.139 In cases of persistent hemodynamic instability or serious bleeding that cannot be localized to 1 segment of the colon, a total colectomy may be necessary.140 Colorectal Dysplasia and Cancer 1. Patients with long-standing Crohn's colitis involving at least one-third of the colon or more than 1 segment, should typically undergo endoscopic surveillance at regular intervals. Grade of recommendation: Strong recommendation based on moderate-quality evidence, 1B. In comparison with an age-matched general population, patients with Crohn's colitis have a 2- to 3-fold increased risk of colorectal cancer, similar to the risk of colorectal cancer developing in patients with UC.141,142 Risk factors for colorectal cancer in patients with CD include disease extent (usually defined as the most extensive disease documented at any time point in a patient's course) and duration, a family history of colorectal cancer, and concomitant primary sclerosing cholangitis (PSC).141,143–146 Although a diagnosis of dysplasia may precede or accompany the diagnosis of adenocarcinoma in patients with Crohn's colitis, cancer can also be the index neoplastic lesion.1,147–150 Although surveillance colonoscopy for patients with CD is endorsed by multiple societies, controversy persists regarding timing and intervals.151 Patients, regardless of the extent of disease at initial diagnosis, should typically undergo screening colonoscopy within 8 years of the onset of symptoms. Exceptions are made for patients with PSC who should typically begin screening at the time of diagnosis and then undergo surveillance annually. Patients with a strong family history of colorectal cancer (age <50, first-degree relative) should typically also undergo more frequent surveillance.141,151 The recommendation for dysplasia
Indocyanine green fluoroscopy has been shown to improve anastomotic leak rates in early phase trials.We hypothesized that the use of fluoroscopy to ensure anastomotic perfusion may decrease anastomotic leak after low anterior resection.We performed a 1:1 randomized controlled parallel study. Recruitment of 450 to 1000 patients was planned over 2 years.This was a multicenter trial.Included patients were those undergoing resection defined as anastomosis within 10 cm of the anal verge.Patients underwent standard evaluation of tissue perfusion versus standard in conjunction with perfusion evaluation using indocyanine green fluoroscopy.Primary outcome was anastomotic leak, with secondary outcomes of perfusion assessment and the rate of postoperative abscess requiring intervention.This study was concluded early because of decreasing accrual rates. A total of 25 centers recruited 347 patients, of whom 178 were randomly assigned to perfusion and 169 to standard. The groups had comparable tumor-specific and patient-specific demographics. Neoadjuvant chemoradiation was performed in 63.5% of perfusion and 65.7% of standard (p > 0.05). Mean level of anastomosis was 5.2 ± 3.1 cm in perfusion compared with 5.2 ± 3.3 cm in standard (p > 0.05). Sufficient visualization of perfusion was reported in 95.4% of patients in the perfusion group. Postoperative abscess requiring surgical management was reported in 5.7% of perfusion and 4.2% of standard (p = 0.75). Anastomotic leak was reported in 9.0% of perfusion compared with 9.6% of standard (p = 0.37). On multivariate regression analysis, there was no difference in anastomotic leak rates between perfusion and standard (OR = 0.845 (95% CI, 0.375-1.905); p = 0.34).The predetermined sample size to adequately reduce the risk of type II error was not achieved.Successful visualization of perfusion can be achieved with indocyanine green fluoroscopy. However, no difference in anastomotic leak rates was observed between patients who underwent perfusion assessment versus standard surgical technique. In experienced hands, the addition of routine indocyanine green fluoroscopy to standard practice adds no evident clinical benefit. See Video Abstract at http://links.lww.com/DCR/B560.ANTECEDENTES:Se ha demostrado que la fluoroscopia con verde de indocianina mejora las tasas de fuga anastomótica en ensayos en fases iniciales.OBJETIVO:Nuestra hipótesis es que la utilización de fluoroscopia para asegurar la irrigación anastomótica puede disminuir la fuga anastomótica luego de una resección anterior baja.DISEÑO:Realizamos un estudio paralelo, controlado, aleatorizado 1:1. Se planificó el reclutamiento de 450-1000 pacientes durante 2 años.AMBITO:Multicéntrico.PACIENTES:Pacientes sometidos a resección definida como una anastomosis dentro de los 10cm del margen anal.INTERVENCIÓN:Pacientes que se sometieron a la evaluación estándar de la irrigación tisular contra la estándar en conjunto con la valoración de la irrigación mediante fluoroscopia con verde indocianina.PRINCIPALES VARIABLES EVALUADAS:El principal resultado fue la fuga anastomótica, y los resultados secundarios fueron la evaluación de la perfusión y la tasa de absceso posoperatorio que requirió intervención.RESULTADOS:Este estudio se cerró anticipadamente debido a la disminución de las tasas de acumulación. Un total de 25 centros reclutaron a 347 pacientes, de los cuales 178 fueron, de manera aleatoria, asignados a perfusión y 169 a estándar. Los grupos tenían datos demográficos específicos del tumor y del paciente similares. Recibieron quimio-radioterapia neoadyuvante el 63,5% de la perfusión y el 65,7% del estándar (p> 0,05). La anastomosis estuvo en un nivel promedio de 5,2 + 3,1 cm en perfusión en comparación con 5,2 + 3,3 cm en estándar (p> 0,05). Se reportó una visualización suficiente de la perfusión en el 95,4% de los pacientes del grupo de perfusión. El absceso posoperatorio que requirió tratamiento quirúrgico fue de 5,7% de los perfusion y en el 4,2% del estándar (p = 0,75). Se informó fuga anastomótica en el 9,0% de la perfusión en comparación con el 9,6% del estándar (p = 0,37). En el análisis de regresión multivariante, no hubo diferencias en las tasas de fuga anastomótica entre la perfusión y el estándar (OR 0,845; IC del 95% (0,375; 1,905); p = 0,34).LIMITACIONES:No se logró el tamaño de muestra predeterminado para reducir satisfactoriamente el riesgo de error tipo II.CONCLUSIÓN:Se puede obtener una visualización adecuada de la perfusión con ICG-F. Sin embargo, no se observaron diferencias en las tasas de fuga anastomótica entre los pacientes que se sometieron a evaluación de la perfusión versus la técnica quirúrgica estándar. En manos expertas, agregar ICG-F a la rutina de la práctica estándar no agrega ningún beneficio clínico evidente. Consulte Video Resumen en http://links.lww.com/DCR/B560. (Traducción-Dr Juan Antonio Villanueva-Herrero).
Abstract Background As one of the 12 clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program, the Colorectal Pathway intends to deliver didactic content organized along 3 levels of performance (competency, proficiency and mastery) each represented by an anchoring procedure (laparoscopic right colectomy, laparoscopic left/sigmoid colectomy, and intracorporeal anastomosis during minimally invasive (MIS) ileocecal or right colon resection). In this article, the SAGES Colorectal Task Force presents focused summaries of the top 10 seminal articles selected for laparoscopic right colectomy which surgeons should be familiar with. Methods Using a systematic literature search of Web of Science, the most cited articles on laparoscopic right colectomy were identified, reviewed, and ranked by the SAGES Colorectal Task Force and invited subject experts. Additional articles not identified in the literature search were included if deemed impactful by expert consensus. The top 10 ranked articles were then summarized, with emphasis on relevance and impact in the field, findings, strengths and limitations, and conclusions. Results The top 10 seminal articles selected for the laparoscopic right colectomy anchoring procedure include articles on surgical techniques for benign and malignant disease, with anatomical and video illustrations, comparative outcomes of laparoscopic vs open colectomy, variations in technique with impact on clinical outcomes, and assessment of the learning curve. Conclusions The top 10 seminal articles selected for laparoscopic right colectomy illustrate the diversity both in content and format of the educational curriculum of the SAGES Masters Program to support practicing surgeon progression to mastery within the Colorectal Pathway.
Background: Enhanced recovery pathways (ERP) are associated with improved recovery. However, data on outcomes following the ERP implementation in colorectal cancer (CRC) are limited. We set out to study the postoperative outcomes, opioid use patterns, and cost impact for patients undergoing colon or rectal resection for cancer.Methods: A retrospective review of all elective CRC resections from January 2015 to June 2018 at a single institution was performed. Patient demographics, operative details, and postoperative outcomes were collected. Colon and rectal patients were studied separately, with comparison of pre-ERP to post-ERP patients.Results: 192 patients underwent elective colorectal resection for cancer. In January 2016, an ERP was implemented for all elective resections – 71 patients underwent surgery in the pre-ERP period (33 colon and 38 rectal) and 121 (56 colon and 65 rectal) occurred in the post-ERP period.There were differences with regard to age, gender, or BMI before or after the implementation of ERP for both groups (all p > 0.05). For both colon and rectal cancer patients, ERP reduced time to regular diet (both p < 0.05) and length of stay (colon: 3 vs. 4 days; rectal: 4 vs. 6 days; both p< 0.01). ERP patients also consumed fewer total narcotics (colon: 44 vs. 184 morphine milligram equivalents (MME), p < 0.01; rectal: 121 vs. 393 MME, p < 0.01).Conclusions: ERP use reduced length of stay and narcotic use with similar total costs and no difference in 30-day complications for both colon and rectal cancer resections.
