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Isolated Ileal Blind Loop Inflammation After Intestinal Resection with Ileocolonic Anastomosis in Crohn's Disease

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Isolated Ileal Blind Loop Inflammation After Intestinal Resection with Ileocolonic Anastomosis in Crohn's Disease Original article Isolated ileal blind loop inflammation after intestinal resection with ileocolonic anastomosis in Crohn’s disease: an often neglected endoscopic finding with an unfavorable outcome a a b a 10/09/2019 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3hZGkqA3HYLNG1i3f3kUb6+JPfW5V/6CKWUY+qSMtCgM= by https://journals.lww.com/eurojgh from Downloaded Evelien M.J. Beelen , Annemarie C. de Vries , Alexander G. Bodelier , Jolyn Moolenaar , W. Rudolph Schoutenc and C. Janneke van der Woudea Downloaded from Objective Postoperative endoscopic recurrence in patients with Crohn’s disease (CD) is commonly classified using https://journals.lww.com/eurojgh the Rutgeerts score. Ulcerations in the ileal blind loop are not taken into account in the Rutgeerts score, and the clinical relevance of these lesions is unknown. This study aimed to assess the outcome of isolated ileal blind loop inflammation (IBLI) in postoperative CD patients. Methods Adult CD patients who underwent intestinal surgery with ileocolonic anastomosis between 1997 and 2017 were included and postoperative endoscopy reports were retrospectively reviewed. IBLI was defined as isolated inflammation of by the ileal blind loop with or without ulcera confined to the anastomosis. Outcome was assessed using endoscopic recurrence BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3hZGkqA3HYLNG1i3f3kUb6+JPfW5V/6CKWUY+qSMtCgM= (Rutgeerts >i2) and surgical recurrence (re-resection). Results A total of 341 CD patients were included. In 125 out of 341 (37%) patients, the ileal blind loop was described in the endoscopy reports. IBLI was reported in 43 of 341 (13%) patients. Start or step-up drug therapy was initiated in 10 of 32 (31%) IBLI patients with abdominal symptoms within a median of 0.9 months [interquartile range (IQR) 0.7–1.4] after ileocolonoscopy. Endoscopic recurrence occurred in 4 out of 38 (11%) IBLI patients without re-resection, within a median of 12.4 months (IQR 6.8–13.3). Intestinal re-resection was performed in 5 out of 43 (16%) IBLI patients within a median of 3.7 months (IQR 3.5–10.8). Conclusion IBLI is associated with symptoms and an unfavorable outcome, with a high risk of endoscopic recurrence in the neoterminal ileum and intestinal re-resection during short-term follow-up. Therefore, the blind ileal loop needs to be assessed during endoscopy in postoperative CD patients. Eur J Gastroenterol Hepatol 31: 1370–1375 Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc. Introduction surgeries in CD patients are ileocecal resections or right Intestinal surgery is a valuable treatment option in patients hemicolectomies with ileocolonic anastomosis [2,4]. with Crohn’s disease (CD). Intestinal resection rates in CD The benefits of surgery are substantial, and a recent patients are estimated at 50–70% within 10 years after randomized controlled trial demonstrated ileocolonic diagnosis [1,2]. Patients with ileal or ileocolonic CD local- resection to be an alternative to step-up therapy with ization have a higher likelihood of undergoing intestinal TNFα-blockers with regard to patient reported quality of resection, with hazard ratios (HRs) of 3.4 and 3.3 respec- life [5]. However, postoperative recurrence is highly prev- tively, when compared with isolated colonic disease local- alent, with endoscopic lesions recurring in up to 80% of ization [2,3]. Consequently, most frequently performed patients within 1 year [6,7]. Current postoperative treat- ment strategies aim at prevention, early detection and on 10/09/2019 early medical treatment of endoscopic lesions [8,9]. In European Journal of Gastroenterology & Hepatology 2019, 31:1370–1375 particular, publication of the Rutgeerts score as a tool to Keywords: anastomosis, blind loop, colonoscopy, Crohn’s disease, classify endoscopic lesions has influenced postoperative endoscopy, ileocecal resection, inflammatory bowel disease, surgery treatment and follow-up strategies. In the landmark study a Department of Gastroenterology and Hepatology, Erasmus University Medical from Rutgeerts et al., the clinical recurrence rates 5 years Center, Rotterdam; bDepartment of Gastroenterology and Hepatology, Amphia hospital, Breda and cDepartment of General Surgery, Erasmus University after endoscopy were assessed in 89 postoperative CD Medical Center, Rotterdam, Netherlands patients, and estimated at 10% for Rutgeerts score of i0 Correspondence to Dr Annemarie C. de Vries, Department of Gastroenterology or i1, 25% for Rutgeerts score i2, 60% for Rutgeerts score and Hepatology, Erasmus University Medical Center, PO Box 2040, 3000 CA, i3 and 100% for Rutgeerts i4 [6]. Rotterdam, The Netherlands Following the observation of mucosal lesions preceding Tel: +0031107038759; fax: +0031107032935; e-mail: [email protected] clinical symptoms, the Rutgeerts score at ileocolonoscopy Received 24 April 2019 Accepted 21 July 2019 has gained a central role in guiding decisions on drug ther- This is an open-access article distributed under the terms of the Creative apy in postoperative CD patients. Pre-emptive ileocolo- Commons Attribution-Non Commercial-No Derivatives License 4.0 (CC-BY- NC-ND), where it is permissible to download and share the work provided it is noscopy early after intestinal resection is recommended properly cited. The work cannot be changed in any way or used commercially in international guidelines [9,10]. A randomised trial without permission from the journal. confirmed the importance of early ileocolonoscopy after 0954-691X Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc. DOI: 10.1097/MEG.0000000000001551 1370 Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Crohn’s isolated ileal blind loop inflammation Beelen et al. www.eurojgh.com 1371 6 months and subsequent step-up drug therapy for endo- Data analysis scopic recurrence, as endoscopic recurrence rates after IBM SPS Statistics version 24.0 (IBM Corp. Released 18 months were significantly lower compared to patients 2013, IBM Corp, Armon, New York) was used for sta- with conventional drug therapy without colonoscopy [8]. tistical analysis. Continuous variables were described Although the Rutgeerts score is a convenient tool as medians and compared using Mann–Whitney U test. during postoperative endoscopy and widely used to Categorical variables were described using proportions estimate the risk of recurrence, it has some limitations. and percentages and compared using χ2 test. Survival sta- Currently, a side-to-side ileocolonic anastomosis is most tistics using Kaplan–Meier analysis was used to describe often used during CD surgery. As end-to-end anastomo- occurrence and time to IBLI diagnosis. The index date for sis was common at the time of publication of the orig- survival analysis for the IBLI population was the date of inal Rutgeerts score, assessment of the Rutgeerts score the last surgery after which IBLI was observed. For the is limited to the anastomosis and neoterminal ileum, background population, the most recent surgery was while the blind ileal loop is not taken into account. The selected as index date. Associated factors for IBLI were prevalence and outcome of isolated inflammation of the identified using Cox proportional hazard analysis. A ileal blind loop are unknown. In this study, we aimed to P-value of <0.05 was accepted as statistically significant. assess the occurrence of isolated ileal blind loop inflam- This study was conducted in accordance with the pro- mation, associated risk factors and outcomes in postop- tocol and the principles of the Declaration of Helsinki. erative CD patients. The study protocol was approved by the Medical Ethical Review Committee of the Erasmus University Medical Materials and methods Center on the 16th of August 2017. Study population Results This multicenter, retrospective study was performed in the Erasmus MC, Rotterdam (academic center) and in the In total, 341 [132 male (39%)] postoperative CD patients Amphia hospital, Breda (large teaching hospital). All adult were included. The ileal blind loop was described in the CD patients (aged ≥18 years) who underwent an intestinal endoscopy report in 125 (37%) patients. IBLI was reported resection with ileocolonic anastomosis between January in 43 of 341 (13%) patients, of whom 19 (6%) patients 1997 and June 2017 were included. The study population had ulcerations limited to the blind loop, and 24 (7%) was identified using Endobase (Olympus corp. Tokyo, patients had IBLI combined with aphthous ulcers confined Japan), a hospital endoscopy registry system in which to the anastomosis (Fig. 1). The main indication for the the type of endoscopy, the indication and the endoscopy endoscopy revealing IBLI was symptoms in 26 (60%) IBLI report are stored [11]. In this endoscopy registry, a search patients, followed by standard work-up after intestinal was performed using the terms (‘Crohn’ and ‘resection’) resection in 9 (21%) IBLI patients and effect monitoring or ‘anastomosis’ or ‘Rutgeerts’ or ‘ileocecal’. Subsequently, of medical therapy in eight (19%) IBLI patients. all hospital records of the obtained patient population The baseline characteristics in the IBLI population were hand searched for the date of surgery. (n = 43) showed no significant differences to the back- ground population (n = 298), with regard to sex, Montreal Data collection Endoscopy reports of the selected patients were reviewed and endoscopic findings at the ileocolonic
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