NEW YORK (Reuters Health) – Following intestinal resection in Crohn’s disease, end-to-end ileocecal anastomosis (ETEA) is associated with better outcomes than is side-to-side anastomosis (STSA), according to a registry study.
“Our findings suggest that the restoration of the intestine as an intact tube (i.e., end-to-end anastomosis) restores function in the postoperative bowel, which translates into better quality of life and less healthcare utilization in the two years after surgery compared with the side-to-side anastomosis,” said Dr. David G. Binion from University of Pittsburgh School of Medicine.
“The inflammatory bowel disease (IBD) expert physicians at our center favor the end-to-end anastomotic configuration for all of these reasons,” he told Reuters Health by email.
STSA, which employs compression stapling devices, has emerged as the dominant approach to anastomotic reconstruction due to its speed and ease of use, compared with a hand-sewn ETEA. There are limited data regarding the comparative outcomes of these two approaches in patients with Crohn’s disease (CD).
To investigate, Dr. Binion and colleagues used prospective observational data from a longitudinal natural history registry on 128 CD patients (68 ETEA and 60 STSA) undergoing their first or second small-bowel resection.
As expected, mean operative time was significantly shorter with STSA (218 min) than with ETEA (257 min), the researchers report in The American Journal of Gastroenterology, online March 6.
During the two years after surgery, STSA patients had significantly higher rates of emergency department visits (33.3% vs. 14.7%), hospitalizations (30% vs. 11.8%) and abdominal CT scans (50% vs. 13.2%).
Median healthcare charges in the two years following surgery were nearly twice as high in the STSA group as in the ETEA group ($11,075 vs. $5,019, P<0.001).
Quality of life scores according to the Short Inflammatory Bowel Disease Questionnaire were significantly worse among STSA patients (47.9) than among ETEA patients (53.4).
The two groups did not differ in CD inflammation recurrence or postoperative complications.
Results were similar among CD patients who received postoperative prophylaxis with immunomodulators and/or biologic agents.
Data from an experimental animal model showed that perpendicular surgical transection of the intestinal circular muscle layers and reconstruction in an anti-peristaltic orientation disrupts motility, which leads to local stasis of the enteric contents and local distention at the anastomotic site.
“Our findings demonstrate that clinical status in postoperative Crohn’s disease patients can be impacted by surgical anastomotic choice,” Dr. Binion said. “The most popular anastomotic approach, with the stapled, side-to-side anti-peristaltic anastomosis, can precipitate functional problems in up to 50% of patients within 2 years of surgery. These symptoms are often difficult to address and are the result of stasis and distention at the anastomotic site, which can trigger pain.”
“Although inflammation is an important driver of symptoms in Crohn’s disease, we saw distinct differences in patients with end-to-end versus side-to-side anastomoses which were independent of inflammation recurrence,” he said.
“Optimal care of the patient with Crohn’s disease represents a partnership between gastroenterologist and surgeon, which will achieve the goal of controlling inflammation but also restoring physiology after resection,” Dr. Binion concluded. “Although the end-to-end anastomosis is more challenging to achieve (compared with the stapled anastomosis), Crohn’s disease patients will have better long-term outcomes and quality of life with this approach.”
The study had no commercial support, and the authors reported no conflicts of interest.
SOURCE: http://bit.ly/2G8PUtW
Am J Gastroenterol 2018.
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