Stefan Holubar, MD, on Hot Topics in Ileocolic Crohn Disease

Dr Holubar discusses new surgical advances in treating ileocolic Crohn disease, including the Kono-S anastamosis and extended mesenteric excision.

Stefan Holubar, MD, is director of research and of the Inflammatory Bowel Disease Surgery section at the Cleveland Clinic in Cleveland, Ohio. 

TRANSCRIPT:

Good afternoon. This is Dr. Holubar from the Department of Colorectal Surgery Cleveland Clinic, where I'm the director of research of the inflammatory bowel disease surgery section. We're going to discuss three hot topics in ileocolic Crohn's disease. The first one is the LIR!C trial.

This is a randomized trial out of Amsterdam Medical Center with Willem Bemelman's group that looked at randomizing patients with 30 centimeters or less of inflammatory phenotype of Crohn's disease to get either treated with Remicade first or surgery first.

Interestingly, what they found was that patients who had surgery first compared with patients who got Remicade first, they both basically had equivalent costs and equivalent outcomes. They did equally well in both groups.

This was a little bit of a paradigm shift within this disease process because previous to this, these patients were always going directly to infliximab therapy, not to ileocolic resection. This study puts IBD surgery as a first treatment of consideration for patients with a purely inflammatory phenotype.

The next topic that we're going to speak about is extended mesenteric excision, and this is another hot topic. Basically, the thought process behind this is when we do traditionally ileocolic resection for Crohn's disease, we would stay very close to the mesentery and not excise to mesentery and its lymph nodes. However, when we do the same operation for colon cancer, we do a high ligation of the ileocolic artery and completing a lymphadenectomy.

In work by Calvin Coffey from Limerick, who happens to be a former graduate of our Colorectal Fellowship Program, he has basically shown and hypothesized that the mesentery plays a strong role in the pathophysiology of Crohn's disease, and this has recently been shown on a basic science level by the Cedars-Sinai group.

It’s a retrospective cohort using historic controls—one cohort of patients who had traditional ileocolic resection to another cohort who had extended mesenteric excision. And although it's a retrospective study, he did show that the recurrence rate after the extended mesenteric excision is performed was an order of magnitude lower than those in the historic cohort. So definitely, this is another area that we're watching very closely and also studying.

Finally, the new kid on the block in terms of surgical technique to try to prevent the recurrence of postoperative Crohn's disease is Kono-S anastomosis. Historically, most ileocolic anastomoses are constructed using a side-to-side stapled anastomodic method and otherwise an end-to-end hand-swen anastomosis. These have been shown in multiple meta-analysis not to have any long-term impact on the recurrence rate for Crohn's disease, but they were somewhat older at this point and I wouldn't necessarily hang my hat on them due to their design.

The another popular type of anastomosis that we favor here at Cleveland Clinic is the stapled end-to-side because it's fast, similar to the stapled side-to-side, but it also recapitulates the normal anatomy of the ileum inserting as a straight longitudal tube into the cecum or right colon. Thus, we do employ both the hand-sewn end-to-end here as well as the stapled end-to-side, but the new kid on the block is a Kono-S anastomosis. This is a hand-sewn antimesenteric side-to-side anastomosis with mesenteric exclusion.

Again, we're coming back to Calvin Coffey's work, whereby we think if you get the anastomosis further away from the mesentery, that might decrease the recurrence rate. In a trial out of Italy, a randomized trial, the Kono-S anastomosis, when it is completed, has an S-type configuration.

The Kono-S anastomosis was shown to be associated with lower post-operative recurrence rate relative to stapled side-to-side anastomosis.

Those are three hot topics based on best available evidence in ileocolic Crohn's disease. Thank you.