Endoscopic Recurrence or Anastomotic Wound Healing Phenomenon after Ileocolic Resection for Crohn’s Disease: The Challenges of Accurate Endoscopic Scoring

Abstract

Background and aims Adequate endoscopic scoring in Crohn’s disease (CD) is crucial, as dictates the need for initiating postoperative medical therapy and is utilized as outcome parameter in clinical trials. We aimed to observe anastomotic wound healing in relation to endoscopic scoring of both inverted and everted stapled lines in side-to-side anastomoses. Methods Two prospective patient cohorts were included: ileocolic resection (ICR) for CD, and right-sided colon resection for colorectal cancer (CRC). Videos taken during colonoscopy six months postoperatively were evaluated. The SES-CD and modified Rutgeerts score were determined. Primary outcome was the presence of ulcerations in CD patients on both the inverted and everted stapled lines. Secondary outcomes were the presence of anastomotic ulcerations in CRC patients and the number of cases having ulcerations exclusively at the inverted stapled line. Results Of the 82 patients included in the CD cohort, ulcerations were present in 63/82 (76·8%) at the inverted- versus 1/71 (1·4%) at the everted stapled line. Likewise in the CRC cohort, ulcerations were present in 4/6 (67·7%) at the inverted versus 0/6 (0%) at the everted stapled line. 27% of the 63 patients in the CD cohort had ulcerations exclusively on the inverted stapled line. Conclusion Inverted stapled lines heal with ulcerations, whereas the everted stapled line heal without any ulcerations, both in CD and non-CD patients. The abnormalities at the inverted stapled line might interfere with endoscopic scoring of recurrence, with potentially an impact on patients’ quality of life and on health-care costs if postoperative treatment is initiated incorrectly.

Optimising surgical anastomosis in ileocolic resection for Crohn’s disease with respect to recurrence and functionality: two international parallel randomized controlled trials comparing handsewn (END-to-end or Kono-S) to stapled anastomosis (HAND2END and the End2End STUDIES)

“…The different adaptation of the cut ends of the bowel determines the type of wound healing. Direct mucosa-to-mucosa adaptation in an everted anastomosis will result in primary wound healing, whereas the serosa-to-serosa adaptation of the longitudinal staple line will heal with secondary intent [ 31 ]. This secondary intent healing involves a process where the mucosa needs to re-epithelialize over the staple line.…”

How Reliable Is Endoscopic Scoring of Postoperative Recurrence in Crohn Disease?: A Systematic Review and Meta-Analysis

“… 96 Recently, we demonstrated that both patients with stapled anastomoses after resection for colorectal cancer and for CD show these ulcerations at 6 months after surgery. 97 These ulcerations might influence endoscopic scoring of recurrence and might lead to overscoring. In fact, when handsewn and Kono-S anastomoses are compared with stapled anastomoses, this normal wound healing phenomenon of the stapled anastomosis may even interfere with the diagnosis disease recurrence when assessing ER.…”