International Journal of Colorectal Disease (2021) 36:1811–1815 https://doi.org/10.1007/s00384-021-03892-z SHORT COMMUNICATION Surgical management of complex ileocolonic Crohn’s disease: a survey of IBD colorectal surgeons to assess variability in operative strategy E Garofalo 1 & F Selvaggi 2 & A Spinelli 3,4 & G Pellino 2 & K Flashman 6 & M Frasson 7 & M Carvello 5 & N de’Angelis 8 & A Garcia-Granero 9 & M Harper 10 & J Warusavitarne 11 & M Coleman 12 & E Espin 13 & V Celentano 10,14 Accepted: 12 February 2021 / Published online: 25 February 2021 # The Author(s) 2021, corrected publication 2021 Abstract Introduction To explore the reported variability in the surgical management of ileocolonic Crohn’ s disease and identify areas of standard practice, we present this study which aims to assess how different colorectal surgeons with a subspecialty interest in inflammatory bowel disease (IBD) surgery may act in different clinical scenarios of ileocolonic Crohn’s disease. Methods Anonymous videos demonstrating the small bowel walkthrough and anonymised patients’ clinical data, imaging and pathological findings were distributed to the surgeons using an electronic tool. Surgeons answered on operative strategy, bowel resections, management of small bowel mesentery, type of anastomosis and use of stomas. Results Eight small bowel walkthrough videos were registered and 12 assessors completed the survey with a questionnaire completion rate of 87.5%. There was 87.7% agreement in the need to perform an ileocolonic resection. However, the agreement for the need to perform associated surgical procedures such as strictureplasties or further bowel resections was only 57.4%. When an anastomosis was fashioned, the side to side configuration was the most commonly used. The preferred management of the mesentery was dissection close to the bowel. Conclusions The decision on the main procedure to be performed had a high agreement amongst the different assessors, but the treatment of multifocal disease was highly controversial, with low agreement on the need for associated procedures to treat internal fistulae and the use of strictureplasties. At the same time, there was significant heterogeneity in the decision on when to anastomose and when to fashion an ileostomy. Keywords Crohn’s disease . Laparoscopic surgery . Colorectal surgery . Ileocaecal resection . Inflammatory bowel disease * E Garofalo 7 Department of General Surgery, Colorectal Unit, La Fe University eleonora.garofalo@uniroma1.it and Polytechnic Hospital, University of Valencia, Valencia, Spain * V Celentano 8 Department of Digestive Surgery, Assistance Publique Hôpitaux de valeriocelentano@yahoo.it Paris, Henri Mondor Hospital, Université Paris-Est (UEP), Créteil, France 1 Department of General Surgery, Sant’Andrea Hospital, La Sapienza 9 University, Rome, Italy Colorectal Surgery, Hospital Universitario Son Espases, Palma de 2 Mallorca, Spain Department of Advanced Medical and Surgical Sciences, Universitádella Campania “Luigi Vanvitelli”, Naples, Italy 10 University of Portsmouth, Portsmouth, UK 3 Department of Biomedical Sciences, Humanitas University, Via Rita 11 Department of Colorectal Surgery, St Mark’s Hospital, Levi Montalcini 4, 20072 Pieve Emanuele, Milan, Italy Harrow, Middlesex, UK 4 IRCCS Humanitas Research Hospital -, via Manzoni 56, 20089 12 Department of Colorectal Surgery, University Hospitals Plymouth Rozzano, Milan, Italy NHS Trust, Plymouth, UK 5 Colon and Rectal Surgery Division, Humanitas University, Rozzano, 13 Milan, Italy Department of General Surgery, Hospital Valle de Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain 6 Colorectal Unit, Queen Alexandra Hospital – Portsmouth Hospitals 14 NHS Trust, Portsmouth, UK Department of Surgery and Cancer, Imperial College, London, UK 1812 Int J Colorectal Dis (2021) 36:1811–1815 Introduction final survey (Appendix 1) included items suggested by com- mittee members as well as items adapted from the Most patients with ileocolonic Crohn’s disease (CD) require MREnterography or ulTRasound in Crohn’s disease surgical intervention during their lifetime, and in view of the (METRIC) study protocol [6] and from the classification of relapsing course of the disease, a multidisciplinary team severity of mesenteric involvement described by Coffey et al. (MDT) approach [1] is mandatory. CD surgery is technically [7]. challenging, and variability may exist amongst colorectal sur- geons in the adoption of different surgical procedures, such as extent of resection and use of bowel sparing techniques, need Survey distribution for diverting stomas or for management of internal fistulae and abscesses. The anonymous videos demonstrating the small bowel To explore this variability in the surgical management of walkthrough were distributed to the committee members to- ileocolonic CD and identify areas of standard practice, we gether with the anonymous survey using an electronic tool present this study which aims to assess how different colorec- (Enalyzer, Denmark, www.enalyzer.com). Anonymised tal surgeons with a subspecialty interest in inflammatory bow- patients’ clinical data, imaging and pathological findings el disease (IBD) surgery may act in different clinical scenarios were also shared with the committee members. of ileocolonic CD, with the primary objective to evaluate the inter-observer variability in the operative strategy in complex Primary and secondary outcomes ileocolonic CD cases, with particular reference to surgical approach, extent and site of resections, use of bowel sparing The primary outcome was the rate of inter-observer variability techniques and diverting stomas. in the operative strategy concerning type of surgical approach, extent and site of resections and strictureplasties and use of diverting stomas. The secondary outcomes were surgical pref- Methods erences for management of the small bowel mesentery and anastomotic configuration. Study setting According to a previous study protocol [2], anonymous lapa- Statistical analysis roscopic videos were recorded and edited at Queen Alexandra Hospital (Portsmouth, UK) to demonstrate the small bowel Categorical variables are presented as frequency or percentage “walkthrough” in patients undergoing laparoscopic and were compared with the use of the chi-squared test or ileocolonic resection for primary and recurrent CD during Fisher’s exact test, as appropriate. Continuous variables are the 3-month study period from March to May 2019. The small presented as mean (±standard deviation) or median (range) bowel walkthrough consisted of the entire exploration of the and were compared with the use of Student’s t test. The small bowel from the Treitz ligament to the ileocaecal valve or Mann-Whitney U test was used for continuous, not normally neo-terminal ileum, using a “hand over hand” technique with distributed outcomes. Inter-rater reliability was estimated by atraumatic forceps [2]. All procedures were performed by a overall percent agreement and by Fleiss’ kappa (ĸ) [8] along single surgeon with expertise in IBD surgery in an attempt to with its 95% confidence interval. ĸ values from 0.21 to 0.4 mitigate the confounding factors of approach variation. were considered as indicating fair agreement, while values from 0.41 to 0.6 and >0.61 were considered as indicating Study design moderate and substantial agreement, respectively. Colorectal surgeons with expertise in minimally invasive sur- gery and IBD were selected as committee members to develop a survey on operative strategy for treatment of complex Results ileocolonic CD. Inclusion criteria for the committee members included evidence of previously published experience in CD Eight small bowel walkthrough videos (Appendix 2) were surgery guideline development [3], distance learning in sur- distributed and 12 assessors completed the survey. Out of gery [4], minimally invasive surgery training programme de- the 672 expected answers, 588 were returned, with a question- velopment and dissemination of online surgical videos [5]. naire completion rate of 87.5%. The quality of the small bowel Twelve experts made up this committee. walkthrough was widely considered acceptable, with asses- The committee identified items for inclusion in the survey sors being unable to comment on the case only in 18 out of by discussion through e-mails and face-to-face meetings. The 588 questions (3%). Int J Colorectal Dis (2021) 36:1811–1815 1813 Surgical resection and associated surgical procedures Discussion There was an agreement of 87.7% amongst the assessors in Our study explored the variability in the intraoperative strate- the need to perform an ileocolic resection (k= 0.82; 95% CI gy in patients undergoing CD surgery, by evaluating via an 0.64, 0.99). However, the agreement for the need to perform anonymous survey the differences in the suggested surgical associated surgical procedures such as strictureplasties, further approach amongst a group of colorectal surgeons with sub- bowel resections or repair of internal fistulae was quite low, specialty interest in IBD and expertise in minimally invasive with an agreement of 57.4% (k=0.36; 95% CI 0.13, 0.59). surgery. The assessors were fully informed of the preoperative Amongst all the assessors, only 1 suggested conversion to data of the patients, including imaging results and were ac- open surgery in one of the procedures (estimated conversion knowledged of the intraoperative findings by edited videos rate of 1.04%). The full results of the survey are shown in demonstrating the laparoscopic small bowel walkthrough. Table 1. The decision on the main procedure to be performed, ileocolonic resection, had a high agreement amongst the dif- Differences in anastomosis formation and ferent assessors; however, how to treat associated disease was defunctioning stoma highly controversial, with very low agreement on the need for associated procedures to treat internal fistulae or use of There was significant heterogeneity in the decision to fashion strictureplasties. At the same time, the decision on when to or not an anastomosis, with an agreement of 70.4% (k = 0.32; anastomose and when to fashion an ileostomy was quite sub- 95% CI 0.08, 0.56). When the anastomosis was not fashioned, jective, with different techniques suggested for the manage- there were reported differences in the management of the dis- ment of the colonic stump, which was left intra-abdominally tal colonic end; however, a double-barrelled stoma (76.4%) as a closed end by some surgeons or brought out as a mucus was the preferred option over a closed intra-abdominal stump fistula or double-barrelled stoma by the majority. Concerning (11.8%) or an ileocolic anastomosis protected by a loop the extent of mesenteric resection, a non-radical resection ileostomy (11.8%). When an anastomosis was fashioned, the seemed the most common approach in our cohort, probably side to side anastomosis was the most commonly used as because of concerns regarding haemorrhagic dangers associ- detailed in Appendix 3. ated with division of the mesentery in patients with CD and potential need for increased length of resected bowel if larger Surgical management of the mesentery mesenteric segments are removed [9]. Our study introduced for the surgeons-assessors the virtual There was significant heterogeneity in the management of the scenario of deciding on the surgical strategy based on the mesentery, with an overall agreement of 45.6% (k= 0.28; 95% preoperative information and a limited view of the macroscop- C.I. 0.15–0.40) with a slight preference for resection of the ic bowel assessment obtained at laparoscopy. The lack of di- mesentery close to the bowel (33.3 to 77.8% of the cases) rect involvement in the preoperative discussion with patient rather than radical cancer-like resection (0 to 41.7%) or resec- and his/her family members creates an artificial scenario tion of macroscopically affected mesentery only ( 0 to 25%). where decisions may not be tailored to the patients’ Table 1 Assessors’ agreement for the need to perform any surgical procedure CASE MAIN PROCEDURE UNABLE TO OTHER ASSOCIATED PROCEDURES COMMENT Ileocaecal No Conversion to Stricturoplasty Other bowel Bladder Primary repair of Abscess resection (%) resection open (%) (%) resection (%) resection (%) colon (%) Debridement (%) (%) 1 90.9 0. 0. 9.1 27.3 0. 0. 0. 0. 2 88.9 0. 0. 11.1 0. 22.2 0. 22.2 0. 3 100 0. 0. 0. 0. 0. 0. 0. 0. 4 100 0. 0. 0. 0. 66.7 0. 22.2 11.1 5 91.7 0. 8.3 8.3 0. 0. 0. 0. 0. 6 100 0. 0. 0. 0. 0. 9.1 0. 27.3 7 72.7 27.3 0. 0. 72.7 0. 0. 0. 0. 8 100 0. 0. 0. 45.4 0. 0. 0. 0. 1814 Int J Colorectal Dis (2021) 36:1811–1815 preferences. Nevertheless, we gave the exact same informa- authors commented on previous version of the manuscript. All authors read and approved the final manuscript. tion to all the blind assessors, who advised on the CD man- agement on the basis of their knowledge and experience for the patient’s best outcome. We must acknowledge this report- Declarations ed variation in preferred surgical approaches and outcomes Ethics approval The study is conducted in accordance with the princi- [10] which could reflect lack of standardisation. The results ples of the Declaration of Helsinki and ‘good clinical practice’ guidelines. of our study strengthen the role of video-based education and Informed consent was obtained from the patients. tele-mentoring to overcome the reported limited surgical trainees’ exposure to these complex procedures [11]. Conflict of interest The authors declare no competing interests. Surgeons could share video recordings of intraoperative find- ings in dedicated teaching sessions of multi-institutional meet- Open Access This article is licensed under a Creative Commons ings, with the aim to enhance surgical training in IBD and Attribution 4.0 International License, which permits use, sharing, facilitate standardisation of surgical techniques. adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the Unfortunately, we did not include the Kono-S anastomotic source, provide a link to the Creative Commons licence, and indicate if technique amongst the options for anastomosis configuration, changes were made. The images or other third party material in this article and therefore the use of the Kono-S anastomosis by the assessors are included in the article's Creative Commons licence, unless indicated has not been evaluated, despite the survey allowing free text otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not insertion for additional comments from the assessors. permitted by statutory regulation or exceeds the permitted use, you will Nevertheless, it should be noted that the Kono-S anastomosis is need to obtain permission directly from the copyright holder. To view a still performed in a small proportion of patients, which was 2.3% copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. according to a recent study reporting on 427 patients undergoing ileocolonic resection for CD [12]. Another obvious limitation of the study is the lack of tactile feedback, which significantly lim- ited the opportunity for the assessors to identify bowel segments References requiring additional interventions, explaining why the use of bowel sparing techniques such as strictureplasties was minimal, 1. Louis E, Dotan I, Ghosh S, Mlynarsky L, Reenaers C, Schreiber S (2015) Optimising the inflammatory bowel disease unit to improve despite the assessors being fully aware of the preoperative MRI quality of care: expert recommendations. imaging. This lack of bowel sparing techniques reflects not only 2. Celentano V, Garofalo E, Spinelli A et al (2020) Video-laparoscopic a selection bias in the videos edited for presentation to the asses- assessment of the small bowel in Crohn’s disease: a comparative study sors but also the difficulties in making a thorough assessment of to evaluate surgeons’ inter-observer variability. Surg Endosc the small bowel involvement at laparoscopy, where a trusty 3. Pellino G, Keller DS, Sampietro GM et al (2020) Inflammatory bowel disease position statement of the Italian Society of agreement may exists amongst surgeons on the presence of bow- Colorectal Surgery (SICCR): Crohn’s disease. Tech Coloproctol el thickening and mesenteric fat wrapping, but not on the evalu- 24(5):421–448 ation of proximal lesions and severity of mesenteric disease. [2] 4. Celentano V, Smart N, Cahill R et al. (2018) LAP-VEGaS practice guidelines for reporting of educational videos in laparoscopic sur- gery: a joint trainers and trainees consensus statement. 5. Celentano V, Browning M, Hitchins C et al. (2017) Training value of laparoscopic colorectal videos on the World Wide Web: a pilot Conclusions study on the educational quality of laparoscopic right hemicolectomy videos. Our study reported high agreement amongst IBD surgeons on the 6. Taylor A, Mallett S et al. (2018) Diagnostic accuracy of magnetic resonance enterography and small bowel ultrasound for the extent main procedure to be performed in selected cases of ileocolonic and activity of newly diagnosed and relapsed Crohn’s disease CD, but the treatment of multifocal disease was highly controver- (METRIC): a multicentre trial. sial, with very low agreement on the need for associated proce- 7. Coffey JC, Kiernan MG, Sahebally SM et al. (2018) Inclusion of dures to treat internal fistulae and the use of strictureplasties. At the mesentery in ileocolic resection for Crohn’s disease is associat- ed with reduced surgical recurrence. the same time, there was significant heterogeneity in the decision 8. Marston (2010) Introductory Statistics for Health and Nursing on when to anastomose and when to fashion an ileostomy. Using SPSS. 9. Buskens CJ, de Groof EJ, Bemelman WA, Wildenberg ME (2017) Supplementary Information The online version contains supplementary ma- The role of the mesentery in Crohn’s disease. terial available at https://doi.org/10.1007/s00384-021-03892-z 10. SICCR Current Status of Crohn’s Disease Surgery Collaborative (2021) National variations in perioperative assessment and surgical management of Crohn’s disease: a multicentre study. Colorectal Author contribution All author contributed to the study conception and Dis 23(1):94–104 design, material preparation, data collection and analysis. The first draft 11. Pellino G, Moggia E, Novelli E, Sturiale A, Martellucci J, Trompetto of the manuscript was written by Garofalo E. and Celentano V. and all M, Gallo G (2019) Italian Society of Colorectal Surgery. An update of Int J Colorectal Dis (2021) 36:1811–1815 1815 the aims and achievements during the first year of the Young Group of resection for Crohn's disease: a multicentre study. Updates Surg. the Italian Society of Colorectal Surgery (Y-SICCR). Tech Coloproctol https://doi.org/10.1007/s13304-020-00918-z 12. Celentano V, Pellino G, Spinelli A, Selvaggi F (2021) SICCR Current status of Crohn’s disease surgery collaborative. Publisher’s note Springer Nature remains neutral with regard to jurisdic- Anastomosis configuration and technique following ileocaecal tional claims in published maps and institutional affiliations.