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xxi
40 Comparison of Surgical Treatments
for Rectal Prolapse
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
LS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
References
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
287
Discussion
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
288
DC
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
288
MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
LS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Index
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291
Contents
1
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
D. Colibaseanu et al., Essential Articles in Colorectal Surgery,
https://doi.org/10.1007/978-3-031-77745-5_1
1
Are Resection Margins
Important inCrohn’s
Disease?
Truong A, Chough J, Zaghiyan KN, Fleshner PR.Risk factors for
microscopic disease positivity at ileocolic resection margins for
Crohn’s disease. Surg Technol Int. 2024;44:99–104.
Abstract
Introduction: Interest in microscopic margin positivity during
surgical resection for medically refractory Crohn’s disease has
been renewed by multiple recent studies showing an association
between microscopic margin positivity with disease recurrence.
Our aim was to determine the risk factors for microscopic margin
disease positivity following ileocolic resection (ICR).
Materials and Methods: A prospectively maintained database
of patients with Crohn’s disease undergoing ICR at a tertiary-
referral center was queried. Margin positivity was dened as the
presence of cryptitis, erosion, transmural inammation with lym-
phoid aggregates, or architectural distortion at either ileal (proxi-
mal) or colonic (distal) margins.
Results: Among 584 patients, 97 patients had a positive micro-
scopic margin (17%), of which 46% had a positive proximal mar-
gin, 17% had a positive distal margin, and 13% had both positive
and distal margins. Using multivariable logistic regression analy-
sis, index ICR was associated with less odds of positive margin
(odds ratio [OR] 0.46, 95% condence interval [CI] 0.24–0.89,
2
p=0.02), and granuloma presence was associated with increased
odds (OR 2.26, 95% CI 1.23–4.21, p=0.01).
Conclusion: We found that repeat ileocolic resection and gran-
uloma presence were predictors of microscopic margin disease.
DC
This is a single institution study of 584 patients addressing the
question of what risk factors are associated with a positive micro-
scopic margin after surgery for Crohn’s disease (CD). This is a
very important question to answer, as microscopically positive
margins are associated with recurrence of disease [1] and, in some
of these recurrences, repeated need for surgery. The macroscopic
appearance of a disease-free margin does not always correlate
with the microscopic analysis [1, 2]. This is not at all a new con-
cern, and it has been attempted to be answered in the past; some
associations were drawn, but the studies were often small and not
necessarily done at high-volume IBD centers [3]. Other studies
have found that smoking and even the number of cigarettes
smoked per day had an association with recurrence but also found
that interestingly enough, longer macroscopically disease-free
resected segments and granuloma presence were not associated
with higher recurrence rates [4].
Decades later, we know that microscopically positive margins
are associated with recurrence of CD at the anastomosis, but what
can we do to minimize this risk? This study found that ileocecal
resections have a higher risk of microscopically positive margins
as did the presence of granulomas. The three questions that this
brings forth are whether frozen section should be routinely
employed, begging the following question, which is how aggres-
sively we should chase “negative margins,” in patients who will
likely have to contemplate in the future additional bowel resec-
tions. The third question that this brings up is in which patients
post resection should we pursue aggressive medical treatment,
and will this aggressive treatment reduce the risk of clinical
relapse which can occur in as much as half of the patients under-
going surgery [5].
1 Are Resection Margins Important inCrohn’s Disease?
3
References
1. Kelm M, Benatzky C, Buck V, etal. Positive resection margins
in Crohn’s disease are a relevant risk factor for postoperative
disease recurrence. Sci Rep. 2024;14:10823. https://doi.
org/10.1038/s41598- 024- 61697.
2. Yzet C, Ruault C, Brazier F, etal. Positive margins and plexitis
increase the risk of recurrence after ileocecal resection: a sys-
tematic review and meta-analysis. Dig Liver Dis.
2023;55(12):1611–20.
3. Kotanagi H, Kramer K, Fazio VW, Petras RE.Do microscopic
abnormalities at resection margins correlate with increased
anastomotic recurrence in Crohn’s disease? Retrospective
analysis of 100 cases. Dis Colon Rectum. 1991;34(10):909–16.
4. van Hogezand RA, Bemelman WA.Management of recurrent
Crohn’s disease. Neth J Med. 1998;53(6):S32–8.
5. Hammoudi N, Cazals-Hatem D, Auzolle C, etal. Association
between microscopic lesions at ileal resection margin and
recurrence after surgery in patients with Crohn’s disease. Clin
Gastroenterol Hepatol. 2020;18(1):141–149.e2.
Discussion
MD
I have not seen the studies looking at increased risk of recurrence
with microscopic positivity. Historically, I know we are always
taught that we really just go to gross margins. So, this was inter-
esting to see with regard to risk factors for microscopic positivity.
I think we would be interested to see in the study if those patients
with positive microscopic margins ended up having increased
recurrence rates. I know this paper was really looking at risk fac-
tors for determining positivity. Are you guys familiar with that
data? Looking at the microscopic disease?
Discussion
4
LS
I have read some studies, and they are very heterogeneous. Among
others, Bruce Wolff at Mayo Clinic in the 1980s looked into that
association. At some point, there was even the impetus to have
frozen sections to ensure the absence of microscopic disease
before anastomosis. Ultimately, all these studies have not indi-
cated that microscopic margins are an important individual factor
predicting recurrence. The prospective randomized study by
Victor Fazio in the 1990s (Fazio, Ann Surg 1996) reafrmed the
still current standard of care of aiming at grossly negative margins
of resection. It compared a proximal small bowel margin of 2cm
from gross disease vs. 12cm, and interestingly, there were some
patients randomized to extended resection who still had some
degree of microscopic Crohn’s disease at their small bowel tran-
section line. As far as I am concerned, the possibility of micro-
scopic disease at the resection margins should not change our
surgical management.
DC
I agree. The question that this brings up is how much effort should
we put in demonstrating whether we have microscopically nega-
tive margins? And then following that, what are we going to do
about it? Denitely a question worth asking, and for now, I do not
know anyone who uses intraoperative frozen section to demon-
strate microscopically negative margins.
MD
I agree. And I do not believe any of the gastroenterologists really
look at the status of microscopic resection margins to determine
whether or not they are going to place patients on medical therapy
after surgery. I think what would also be interesting, now that a lot
of people are doing intracorporeal anastomosis and not actually
1 Are Resection Margins Important inCrohn’s Disease?
5
feeling the specimens is whether or not there has been a difference
in positive resection margin or recurrence between robotic intra-
corporeal anastomosis vs. extracorporeal where it is possible to
actually feel the tissue rather than just assessing the bowel by eye.
I do not think that it has been looked at, but I know when I rst
started doing intracorporeal anastomosis, it is straightforward for
the obvious, gross disease. However, for those patients with more
subtle disease or who may have multifocal strictures, I am a little
bit more wary, and I have extracorporealized some small bowels
just to further assess it with palpation, if I am ever concerned
about that.
LS
I agree. The other intervening factor in the robotic anastomosis is
the anastomotic conguration, which could also become the sub-
ject of debate because most of the time we would not do isoperi-
staltic side-to-side anastomosis in open or laparoscopic surgery. I
do not have a lot of robotic experience, but I do agree that in some
cases, I felt that I could not just visually assess the presence of
additional Crohn’s disease somewhere else in the small bowel
besides the segment which was being resected, and I decided to
exteriorize because of that.
Discussion
7
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
D. Colibaseanu et al., Essential Articles in Colorectal Surgery,
https://doi.org/10.1007/978-3-031-77745-5_2
2
Handsewn vs. Stapled
Ileocolic Anastomosis
inCrohn’s Disease
McLeod RS, Wolff BG, Ross S, Parkes R, McKenzie M,
Investigators of the CAST Trial. Recurrence of Crohn’s disease
after ileocolic resection is not affected by anastomotic type:
results of a multicenter, randomized, controlled trial. Dis Colon
Rectum. 2009;52(5):919–27.
Abstract
Purpose: This study attempts to determine whether stapled side-
to-side anastomosis, compared with handsewn end-to-end anasto-
mosis, results in decreased recurrence of Crohn’s disease
following ileocolic resection.
Methods: Patients with Crohn’s disease who underwent an
ileocolic resection were randomized to side-to-side anastomosis
or end-to-end anastomosis. Colonoscopy was performed at 12
months. The primary outcome was endoscopic recurrence, while
the secondary outcome was symptomatic recurrence (dened as
symptoms attributable to Crohn’s disease and severe enough to
warrant treatment, plus endoscopic disease recurrence).
Results: One hundred and thirty-nine subjects were included
in the efcacy analysis. After a mean follow-up of 11.9 months,
the endoscopic recurrence rate was 42.5% in the end-to-end anas-
tomosis group, compared with 37.9% in the side-to-side anasto-
mosis group (4.6% difference; 95% condence interval
21.0–11.9%; P = 0.55). The symptomatic recurrence rate was
8
21.9% in the end-to-end anastomosis group, compared with
22.7% in the side-to-side anastomosis group (+0.8% difference;
95% condence interval 13.2–15.3%; P= 0.92). In multivariate
logistic regression analysis, previous resections were predictive of
a higher risk of both endoscopic (odds ratio 1.78; 95% condence
interval 1.06–2.90; P=0.028) and symptomatic (odds ratio 2.0;
95% condence interval 1.14–3.60; P=0.0016) recurrence. Com-
pliance with postoperative maintenance therapy was predictive of
a lower risk of symptomatic recurrence (odds ratio 0.13, 95%
condence interval 0.01–0.78; P=0.021).
Conclusion: Recurrence rates are similar whether end-to-end
anastomosis or side-to-side anastomosis is performed.
LS
This is a randomized trial comparing two anastomotic techniques
in the management of ileocolic resection for Crohn’s disease
which has dened my agnostic attitude toward this issue ever
since. The Canadian and American Surgical Crohn’s Disease Trial
(CAST) randomized end-to-end versus side-to-side ileocolic
anastomosis. This basically ended up being a comparison between
handsewn versus stapled anastomosis. This trial had been designed
based on the hypothesis that a wider side-to-side stapled anasto-
mosis could be associated with a longer time to recurrence. The
assumption at the time was that “a narrow anastomosis may lead
to fecal stasis and increase the likelihood of recurrence of dis-
ease.” The outcomes of interest were endoscopic recurrence and
symptomatic recurrence. One hundred thirty-nine patients were
randomized in 17 different centers. The patient enrollment in the
study was stopped in 2004 due to slow accrual. After a mean fol-
low-up of 11.9 months, there were no differences between the
groups in either endoscopic or symptomatic recurrence. The anas-
tomotic leak rates were 7% in either group. This is obviously an
old trial at a time when many of the currently available medica-
tions were not available. For example, 22% and 16% of the end-
to-end group and side-to-side group, respectively, were on
prednisone preoperatively. Modern medical prophylaxis after sur-
2 Handsewn vs. Stapled Ileocolic Anastomosis inCrohn’s Disease
9
gery could be associated with improved results across the board at
least in terms of endoscopic and symptomatic recurrence 1year
postoperatively. However, this study because of its design clari-
ed the lack of benet associated with the stapled anastomosis at
least in terms of disease recurrence. This randomized trial had
been planned based on some encouraging results deriving from
earlier retrospective, observational studies, which are referenced
in the paper. This to me conrms that observational studies should
not be viewed as sufcient evidence to support the adoption of
one particular anastomotic technique over another. It is interesting
to note that the debate on the ideal surgical technique for ileocolic
anastomosis after ileocolic resection for Crohn’s disease contin-
ues to this day, almost 20years after the accrual for this study was
terminated. The European Crohn’s and Colitis Organisation
guidelines from 2020 continue recommending stapled rather than
handsewn ileocolic anastomosis because of a decreased risk of
anastomotic complications [1]. Therefore, the preference for sta-
pled anastomosis in this case does not derive from a perceived
advantage in reducing the risk of disease recurrence. At the oppo-
site side of the spectrum, there are advocates of a handsewn anas-
tomosis [2]. More recently, a new anastomotic technique loosely
based on the surgical principles of strictureplasty was proposed
by the late Dr. Toru Kono in Japan, the Kono-S anastomosis [3].
The letter “S” stands for support, which would be provided by the
preservation of the mesentery close to the bowel utilized to per-
form the anastomosis. On the other hand, there is also a school of
thought advocating wide excision of the mesentery during ileoco-
lic resection to reduce disease recurrence [4], and the combination
of wide mesenteric excision and Kono anastomosis has also been
proposed [5]. A recent prospective randomized trial has suggested
that Kono-S ileocolic anastomosis is associated with a reduced
rate of endoscopic recurrence when compared to stapled side-to-
side ileocolic anastomosis [6]. If conrmed by other similarly
designed studies, this could potentially lead to a change in prac-
tice. Until then, I do not expect that any anastomotic technique is
associated with a different risk of disease recurrence rate. When
the small bowel proximal to a severe stricture is dilated with
boggy, thickened bowel wall because of chronic obstructive
LS
10
symptoms, I prefer to do an end-to-end anastomosis because I am
concerned that the mechanical stapler might not be effective on
thickened, edematous bowel wall. On the other hand, if there is a
discrepancy between a narrow diameter in the terminal ileum and
a much larger ascending colon, I typically favor a side-to-side
anisoperistaltic stapled anastomosis. With the advent of robotic
technique and intracorporeal anastomosis, there is another anasto-
motic type which is gaining favor, a side-to-side isoperistaltic
ileocolic anastomosis using a robotic stapler with the closure of
the resulting defect using running intracorporeal sutures [7].
Advocates of the robotic approach emphasize its recovery and
morbidity advantages and consider this technique safe and feasi-
ble but do not postulate any presumed benets in reducing Crohn’s
disease recurrence rates.
References
1. Adamina M, Bonovas S, Raine T, Spinelli A, Warusavitarne J,
Armuzzi A, Bachmann O, Bager P, Biancone L, Bokemeyer B,
Bossuyt P, Burisch J, Collins P, Doherty G, El-Hussuna A,
Ellul P, Fiorino G, Frei-Lanter C, Furfaro F, Gingert C,
Gionchetti P, Gisbert JP, Gomollon F, González Lorenzo M,
Gordon H, Hlavaty T, Juillerat P, Katsanos K, Kopylov U,
Krustins E, Kucharzik T, Lytras T, Maaser C, Magro F,
Marshall JK, Myrelid P, Pellino G, Rosa I, Sabino J, Savarino
E, Stassen L, Torres J, Uzzan M, Vavricka S, Verstockt B,
Zmora O. ECCO guidelines on therapeutics in Crohn’s dis-
ease: surgical treatment. J Crohns Colitis. 2020;14(2):155–68.
2.
Gajendran M, Bauer
AJ, Buchholz BM, Watson AR,
Koutroubakis IE, Hashash JG, Ramos-Rivers C, Shah N, Lee
KK, Cruz RJ, Regueiro M, Zuckerbraun B, Schwartz M,
Swoger J, Barrie A, Harrison J, Hartman DJ, Salgado J, Rivers
WM, Click B, Anderson AM, Umapathy C, Babichenko D,
Dunn MA, Binion DG. Ileocecal anastomosis type signi-
cantly inuences long-term functional status, quality of life,
and healthcare utilization in postoperative Crohn’s disease
patients independent of inammation recurrence. Am J
Gastroenterol. 2018;113(4):576–83.
2 Handsewn vs. Stapled Ileocolic Anastomosis inCrohn’s Disease