Ileocecectomy for Crohn's Disease (CD): Which Factors Augment Intraoperative Small Bowel Preservation?
Liliana Bordeianou*1, Richard a. Hodin1, Abdulmetin Dursun1, Joshua R. Korzenik1, Vanessa P. Ho2, Toyooki Sonoda2, Sang Lee2, Sharon L. Stein3
1Surgery, Massachusetts General Hospital, Boston, MA; 2Colorectal Surgery, Cornell University, New York, NY; 3Colorectal Surgery, Case Western University, Cleveland, OH
Introduction: Preservation of small bowel is a crucial element in surgery for patients with CD, yet it is not known whether perioperative factors or preoperative therapies influence specimen length. Our aim was to utilize a large multicenter database of CD patients treated with ileocecectomies (IC) to determine predictors of length of small bowel resection.Methods: Retrospective analysis of prospectively collected data on patients with CD who underwent IC between 9/1993-10/2010 at two academic centers was performed. T-tests were used to determine whether the mean length of small bowel resection (length of colon excluded) was modified by patient demographics, preoperative medical treatment, type of CD, or surgeon expertise. A Multiple Linear Regression model was fitted to account for confounders and to identify predictors of length of resection.Results: 269 CD patients (51% female, mean age 39 y) were included. On univariate analysis, the mean length of small bowel resection(20.8 cm, SD 17.18 cm) was not affected by age (p= 0.23), sex (p=0.12), history of prior resections (p=0.12), emergency surgery (p=0.23), presence of fibrostenotic (p=0.51), penetrating (p=0.78) or active disease (p=0.97). Patients with microscopically positive margins were not spared bowel length (22.5 vs. 19.8 cm, p=0.34). Patients with suspected malignancy had wider resection margins(54.7 vs. 19.6 cm, p=0.01). 5-ASA (p=0.54), steroids (p=0.51), azathioprine (p=0.59) and TNF agents (p=0.13) did not augment length of resection, however exposure to 6-MP within 3 months of surgery decreased resection length (17.1 vs. 22.4, p=0.03). Surgeons with expertise in CD were more likely to salvage bowel (19.9 vs. 29.5 cm; p=0.0008). On multiple linear regression history of prior resections (p=0.0001), suspected malignancy (p=0.02) and surgery by a non-expert (p=0.0004) were predictive of longer resections.Conclusions: Length of small bowel resection during ileocolic resection for CD is most affected by surgical expertise, concerns for malignancy and history of prior resections. Various preoperative medical regimes do not appear to have an effect on ultimate resection length.
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