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Enteritis cystica profunda is a rare and benign disease defined as the invagination of the intestinal epithelium into the submucosa and more profound layers of intestinal wall leading to the formation of mucin-filled cystic spaces. We reported the case of a 45-year-old female, suffering from a Crohn's disease, with a Koenig's syndrome, diarrhea, abdominal pain and weight loss. The colonoscopy and the abdominopelvic scan showed a terminal ileal stenosis, with parietal calcifications. A surgical ileocecal resection was decided. Gross examination of the ileocecal resection showed a thickening of the ileal wall, with many mucin-filled cysts measuring 1mm to 2cm, with some calcifications. The ileal mucosa was ulcerated, and showed a stenotic sector extending over 3cm. Histological examination showed acute ulcerated ileitis lesions, with chronic ileitis lesions and stenosis, compatible with the known diagnosis of Crohn's disease. There were also many cysts into the ileal wall. They were lined with a regular ileal epithelium. The cysts contained mucus, with some calcifications. Some cysts were ruptured, with extravasation of mucus within the wall. Cystica profunda can be found anywhere along the digestive tract. The physiopathology is not yet well understood, but it seems to be favored by chronic aggression of the intestinal wall. This pathology most often coexists with Crohn's disease. The main differential diagnosis is mucinous adenocarcinoma. Cystica profunda does not require any specific treatment., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Competing Interests: The authors declare that they have no conflict of interest.

Background: Most Crohn's disease [CD] patients require surgery. Ileitis recurs after most ileocolectomies and is a critical determinant for outcomes. The impacts of ileocolectomy-induced bile acid [BA] perturbations on intestinal microbiota and inflammation are unknown. We characterized the relationships between ileocolectomy, stool BAs, microbiota and intestinal inflammation in inflammatory bowel disease [IBD]., Methods: Validated IBD clinical and endoscopic assessments were prospectively collected. Stool primary and secondary BA concentrations were compared based on ileocolectomy and ileitis status. Primary BA thresholds for ileitis were evaluated. Metagenomic sequencing was use to profile microbial composition and function. Relationships between ileocolectomy, BAs and microbiota were assessed., Results: In 166 patients, elevated primary and secondary BAs existed with ileocolectomy. With ileitis, only primary BAs [795 vs 398 nmol/g, p = 0.009] were higher compared to without ileitis. The optimal primary BA threshold [≥228 nmol/g] identified ileitis on multivariable analysis [odds ratio = 2.3, p = 0.04]. Microbial diversity, Faecalibacterium prausnitzii and O-acetylhomoserine aminocarboxypropyltransferase [MetY] were decreased with elevated primary BAs. Amongst ileocolectomy patients, only those with elevated primary BAs had diversity, F. prausnitzii and MetY reductions. Those with both ileocolectomy and intermediate [p = 0.002] or high [≥228 nmol/g, p = 9.1e-11]] primary BA concentrations had reduced F. prausnitzii compared to without ileocolectomy. Those with ileocolectomy and low [<29.2 nmol/g] primary BA concentrations had similar F. prausnitzii to those without ileocolectomy [p = 0.13]. MetY was reduced with ileitis [p = 0.02]., Conclusions: Elevated primary BAs were associated with ileitis, and reduced microbial diversity, F. prausnitzii abundance and enzymatic abundance of MetY [acetate and l-methionine-producing enzyme expressed by F. prausnitzii], and were the only factors associated with these findings after ileocolectomy., (© The Author(s) 2022. Published by Oxford University Press on behalf of European Crohn’s and Colitis Organisation. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

A 39-year-old female was diagnosed with inflammatory bowel disease unclassified (IBD-U) in 2011, during the post-partum period, after developing chronic bloody diarrhea and marked weight loss. She underwent colonoscopy showing erosive ileitis and pancolitis. Biopsies were compatible with unspecified chronic ileocolitis.

In March 2008, I published an article in this journal that examined the ways in which the White House managed the news -- and minimized the political impact -- of Dwight D. Eisenhower's massive 1955 heart attack. In addition, the analysis explored the manner in which Eisenhower himself, in handling this issue, had brilliantly "manipulated his medical team, safeguarded his image, cajoled his staff, confused the press, managed his advisers, dominated his party, and ran a campaign that was virtually impossible for the opposition to counteract" (p. 18).[1] This article expands on my previous work by considering the ways in which Eisenhower's ill health had significant public policy repercussions that went beyond the immediate political effects evaluated in 2008. These included the drawbacks associated with Eisenhower's concept of "Team Government," a tragic war in the Middle East, a serious deterioration of the U.S. relationship with three very close allies and, finally, the beginnings of a presidentially led effort to add a much needed "presidential disability" amendment to the United States Constitution. These latter effects have been studied here through use of primary source materials located at the Dwight D. Eisenhower Presidential Library, commentaries written by Eisenhower himself, members of his family and other close associates and the voluminous secondary literature that has appeared over the years focusing on the Eisenhower presidency. [ABSTRACT FROM AUTHOR]

A possible classical complication of Crohn's disease is the formation of a stenosis, which can occur throughout the course of the disease and can present differently depending on the narrowing of the lumen. This article reports the case of a 39-year-old male patient with a stenosing terminal ileitis, which was ultimately only manifested after obstruction by a foreign body.

Background and Aims: Postoperative recurrence remains a challenging problem in patients with Crohn's disease [CD]. To avoid development of short bowel syndrome, strictureplasty techniques have therefore been proposed. We evaluated short- and long-term outcomes of atypical strictureplasties in CD patients with extensive bowel involvement., Methods: Side-to-side isoperistaltic strictureplasty [SSIS] was performed according to the Michelassi technique or modification of this over the ileocaecal valve [mSSIS]. Ninety-day postoperative morbidity was assessed using the comprehensive complication index [CCI]. Clinical recurrence was defined as symptomatic, endoscopically or radiologically confirmed, stricture/inflammatory lesion requiring medical treatment or surgery. Surgical recurrence was defined as the need for any surgical intervention. Endoscopic remission was defined as ≤i1, according to the modified Rutgeerts score. Deep remission was defined as the combination of endoscopic remission and absence of clinical symptoms. Perioperative factors related to clinical recurrence were evaluated., Results: A total of 52 CD patients [SSIS n = 12; mSSIS n = 40] were included. No mortality occurred. Mean CCI was 10.3 [range 0-33.7]. Median follow-up was 5.9 years [range 0.8-9.9]. Clinical recurrence [19 patients] was 29.7% and 39.6% after 3 and 5 years, respectively. Surgical recurrence [seven patients] was 2% and 14.1% after 3 and 5 years, respectively. At the end of the follow-up, 92% of patients kept the original strictureplasty and deep remission was observed in 25.7% of the mSSIS patients. None of the perioperative variables considered showed a significant association with clinical recurrence., Conclusions: SSIS is safe, effective, and provides durable disease control in patients with extensive CD ileitis., (© The Author(s) 2020. Published by Oxford University Press on behalf of European Crohn’s and Colitis Organisation. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Perioperative mortality rate (POMR) has been identified as an important measure of access to safe surgical and anesthesia care in global surgery. There has been limited study on this measure in rural Ghana. In order to identify areas for future quality improvement efforts, we aimed to assess the epidemiology of exploratory laparotomy and to investigate POMR as a benchmark quality measure., Methods: Surgical records were reviewed at a regional referral hospital in Eastern Region, Ghana to identify cases of exploratory laparotomy from July 2017 through June 2018. Patient demographics, health information, and outcomes data were collected. Logistic regression was used to identify predictors of perioperative mortality., Findings: The study included operations for 286 adult and 60 pediatric patients. Only 60% of patients were covered by National Health Insurance (NHI). The overall POMR was 11.5% (12.6% adults; 6.7% pediatric). Sixty percent of mortalities were referrals from outside hospitals and the mortality rate for referrals was 13.5%. Odds of mortality was 13 times greater with perforated peptic ulcer disease (OR = 13.1, p = 0.025) and 12 times greater with trauma (OR = 11.7, p = 0.042) when compared to the most common operation. Female sex (OR = 0.3, p = 0.016) and NHI (OR = 0.4, p = 0.031) were protective variables. Individuals 60 years and older (OR = 3.3, p = 0.016) had higher mortality., Conclusion: POMR can be an important outcome and quality indicator for rural populations. Interventions aimed at decreasing emergent hernia repair, preventing perforation of peptic ulcer disease, improving rural infrastructure for response to major trauma, and increasing NHI coverage may improve POMR in rural Ghana., Competing Interests: All authors declare no financial relationships with any organizations with interest in the submitted work., (Copyright: © 2020 The Author(s).)

Background: Repeated intestinal resections may have disabling consequences in patients with Crohn's disease even in the absence of short bowel syndrome. Our aim was to evaluate the length of resected small bowel in patients undergoing elective and emergency surgery for ileocolic Crohn's disease., Methods: A prospective observational study was conducted on patients undergoing surgery for ileocolonic Crohn's disease in a single colorectal centre from May 2010 to April 2018. The following patients were included: (1) patients with first presentation of ileocaecal Crohn's disease undergoing elective surgery; (2) patients with ileocaecal Crohn's disease undergoing emergency surgery; (3) patients with recurrent Crohn's disease of the distal ileum undergoing elective surgery. The primary outcomes were length of resected small bowel and the ileostomy rate. Operating time, complications and readmissions within 30 days were the secondary outcomes., Results: One hundred and sixty-eight patients were included: 87 patients in the elective primary surgery group, 50 patients in the emergency surgery group and 31 in the elective redo surgery group. Eleven patients (22%) in the emergency surgery group had an ileostomy compared to 10 (11.5%) in the elective surgery group (p < 0.0001). In the emergency surgery group the median length of the resected small bowel was 10 cm longer than into the group having elective surgery for primary Crohn's disease., Conclusions: Patients undergoing emergency surgery for Crohn's disease have a higher rate of stoma formation and 30-day complications. Laparoscopic surgery in the emergency setting has a higher conversion rate and involves resection of longer segments of small bowel.

T cell clonal expansions are present in the inflamed mucosa of patients with Crohn's disease (CD) and may be implicated in postoperative recurrence after ileocolonic resection., Methods: T cell receptor (TCR) analysis was performed in 57 patients included in a prospective multicentre cohort. Endoscopic recurrence was defined by a Rutgeerts score >i0. DNA and mRNA were extracted from biopsies collected from the surgical specimen and endoscopy, and analysed by high throughput sequencing and microarray, respectively., Results: TCR repertoire in the mucosa of patients with CD displayed diverse clonal expansions. Active smokers at time of surgery had a significantly increased proportion of clonal expansions as compared with non-smokers (25.9%vs17.9%, p=0.02). The percentage of high frequency clones in the surgical specimen was significantly higher in patients with recurrence and correlated with postoperative endoscopic recurrence (area under the curve (AUC) 0.69, 95% CI 0.54 to 0.83). All patients with clonality above 26.8% (18/57) had an endoscopic recurrence. These patients with a high clonality were more frequently smokers than patients with a low clonality (61% vs 23%, p=0.005). The persistence of a similar TCR repertoire at postoperative endoscopy was associated with smoking and disease recurrence. Patients with high clonality showed increased expression of genes associated with CD8 T cells and reduced expression of inflammation-related genes. Expanded clones were found predominantly in the CD8 T cell compartment., Conclusion: Clonal T cell expansions are implicated in postoperative endoscopic recurrence. CD patients with increased proportion of clonal T cell expansions in the ileal mucosa represent a subgroup associated with smoking and where pathogenesis appears as T cell driven., Trial Registration Number: NCT03458195., Competing Interests: Competing interests: MA received honoraria from Abbvie, MSD, Janssen, Takeda, Pfizer, Novartis, Ferring, Tillots, Celgene and Genentech/Roche. SN received honoraria from MSD, Abbvie, Takeda, Janssen, HAC Pharma, Tillots, Ferring and Novartis. AB received honoraria from MSD, Abbvie, Ferring, Takeda, Vifor Pharma, Sanofi‐Aventis, Hospira and Janssen. BP received honoraria from AbbVie, MSD, Takeda, Janssen, Bioagaran and Ferring. MF received honoraria from AbbVie, MSD, Takeda, Janssen, Pfizer, Ferring and Boehringer. HS received unrestricted study grants: Danone, Biocodex and Enterome; board membership, consultancy, or lecture fees: Carenity, Abbvie, Astellas, Danone, Ferring, Mayoly Spindler, MSD, Novartis, Roche, Tillots, Enterome, Maat, BiomX, Biose, Novartis and Takeda; cofunder of Nextbiotix. XT received honoraria from Abbvie, MSD, Takeda, Ferring, Norgine and Janssen. PS received honoraria from Takeda, MSD, Biocodex, Ferring and Abbvie, and non-financial support from Takeda. CA, MN, HB, VC, AMC, AS, CS and NB declare no competing interest., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The inflammation encountered in Crohn's disease makes a minimally invasive approach challenging due to a thickened mesentery, fistulas, abscesses, and large phlegmons with high reported rates of conversion and septic complications. Aim of this study was to evaluate the feasibility of a stepwise approach to training in laparoscopic surgery for complex Crohn's disease., Methods: Every surgical procedure was divided in 4 different training tasks: access and exposure, bowel mobilization, division of the mesentery, anastomosis. Extensive adhesiolysis and division and repair of fistulae were considered as additional tasks when present. The laparoscopic competence assessment tool was used to evaluate the safety and proficiency of the surgical performance. The primary outcome was the rate of training tasks successfully completed by surgical trainees., Results: One hundred and twenty seven training episodes were included and 86 were performed by trainees (67.7%). Fistula division was the less commonly performed training task (25%), while mobilisation and anastomosis were performed by the supervised trainee in 90% and 85% of the cases. Safety and proficiency scores were significantly higher for senior trainees compared to junior trainees., Conclusions: Laparoscopic surgery for complex Crohn's disease can be safely performed in a supervised setting with acceptable operating time, postoperative length of hospital stay, and 30 day morbidity., (Copyright © 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Magnetic resonance enterography [MRE] is the gold standard for assessing ileal inflammation in Crohn's disease [CD]. The aim of the present study was to correlate faecal calprotectin [FC] to MRE via a simple score in an exclusive ileal cohort with long-term follow-up for association with time to surgery or biologic therapy., Methods: In total, 150 MRE studies with matched FC [±30 days] were identified from the Edinburgh FC Register [2008-12; n = 18138]. Scans were re-read blinded to clinical data, independently, by two expert gastrointestinal radiologists, to generate a simple MRE score [range 0-10] from assessment of the worst intestinal segment plus total disease extent., Results: In total, 119 MRE scans were evaluated from 104 patients with ileal CD [L1 or L3 with panproctocolectomy]. Receiver operating characteristic analysis showed an area under the curve of 0.77 [0.67-0.87, p < 0.0001] for FC and MRE score >1, with an optimal cut-off of 145 μg/g for severe inflammation on MRE with 69.3% [57.6-79.5] sensitivity and 71.4% [53.7-85.4] specificity. Long-term follow-up over a median [interquartile range] of 2086 days [1786-2353] revealed FC ≥ 145 μg/g was associated with reduced biologic-free survival until 3 years following MRE, whereas MRE score [severe vs absent] was associated with reduced surgery- and biologic-free survival throughout follow-up. Backwards stepwise logistic regression revealed that length of ileal disease (odds ratio [OR] 3.8, 1.1-13.2, p = 0.034) and increased bowel wall thickness at MRE [OR 4.2, 1.6-10.7, p < 0.0001] or female sex [OR 5.2, 1.5-18.7, p = 0.011] increased the risk of biologic use or surgery, respectively., Conclusions: FC correlates well with MRE assessment of ileal CD with MRE parameters associated with long-term biologic- and surgery-free remission., (Copyright © 2018 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Despite the improvement of medical therapies, nearly half of patients with Crohn's disease require surgery within 10 years after diagnosis. However, intestinal resection is not curative and recurrence may occur., Aims: To evaluate post-surgical outcomes for patients with Crohn's disease in a large monocentric cohort, and to identify variables associated with clinical and surgical relapse., Methods: Patients with Crohn's disease who had surgery for ileal and colonic Crohn's disease between 2004 and 2016 and on at least one-year follow-up following surgery were included., Results: One hundred ninety-three patients were included in the study. Crohn's disease recurrence concerned 53% of patients after a median 56-month (6-158) follow-up and 29% of patients required a second surgical intervention. At logistic regression analysis, active smoking and young age at diagnosis were identified as independent risk factor for post-surgical relapse (p = 0.01), while colonic or ileocolonic resection was recognized as a risk factor for surgical Crohn's disease relapse (p = 0.003)., Conclusions: Post-surgery recurrence is frequent for patients with Crohn's disease. Active smoking and young age at diagnosis are risk factors for Crohn's disease recurrence. As compared with patients undergoing small-bowel surgery, patients with colonic resection are proner to relapse requiring a second surgical intervention., (Copyright © 2018 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Ingestion of foreign bodies such as fish bone or chicken bone is relatively common in adults; however, resultant transmural migration is extremely rare., Methods: We present a case of a 79-year-old woman with chronic low-grade abdominal pain, worsening over the last 4 days. Computed tomography revealed segmental small bowel wall thickening with chronic inflammation suggestive of Crohn's ileitis and oral steroids were commenced; only later, ingestion of a foreign body was suspected., Results and Conclusion: At diagnostic laparoscopy, a linear foreign body resembling a wooden splinter was identified. It had partly migrated through the chronically inflamed bowel wall without causing perforation or abdominal contamination. It was removed laparoscopically without an enterotomy or bowel resection. Microscopy revealed non-viable bone, likely fish or chicken bone. The patient made an uneventful recovery and was discharged 3 days later. Herein we emphasise on the differential diagnosis and presentation of chronically ingested foreign bodies, as well as the feature of chronic ileitis with uncomplicated transmural migration of the ingested foreign body that was treated laparoscopically without an enterotomy.

A 9-month-old neutered male rabbit was referred for lethargy, anorexia, and gastrointestinal stasis. Routine hematology, serum biochemistry, and diagnostic imaging were performed. Computed tomography revealed a wall thickening of the sacculus rotundus and appendix, which was further confirmed on abdominal ultrasound. Full thickness biopsies were collected with histopathology diagnosing a chronic multifocal heterophilic granulomatous sacculitis and appendicitis. The patient was treated medically and at 6 weeks follow-up, clinical signs and intestinal changes had completely regressed. Inflammation of the sacculus rotundus and appendix should be considered as a cause of gastrointestinal stasis in rabbits., (© 2018 The Authors. Veterinary Radiology & Ultrasound published by Wiley Periodicals, Inc. on behalf of American College of Veterinary Radiology.)

Rationale: The rare disease cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is characterized by multiple and recurring small intestinal ulcers with stenosis of unknown causes. In clinic, it is difficult to be differentiated from the inflammatory bowel disease, especially the Crohn disease., Patient Concerns: Here we report a pair of siblings who suffered from long-time anemia and abdominal pain and misdiagnosed with inflammatory bowel disease (IBD) for many years., Diagnoses: They were finally diagnosed with CMUSE with intestinal obstruction., Interventions and Outcomes: They both accepted surgical treatment and recovered well. No abdominal symptom appeared in the two-year follow-up., Lessons: This report underscores that CMUSE patients may have a long course of suffering from anemia and abdominal pain, normal inflammatory markers and normal colon, and sometimes have a family history of CMUSE. Surgery of segmental bowel resection is a good way to solve intractable intestinal obstruction in CMUSE.

Background: We have previously recognized segmental sigmoid polyps as an indicator of a fistula from Crohn's ileitis to the sigmoid or the proximal rectum. In the course of this study, we realized that many patients with this fistula had no sigmoid polyps, but the sigmoid was the site of marked inflammation and early or late stricture formation. Furthermore, in some patients with a stricture, the fistula was not recognized until the surgeon (or the pathologist) dissected an inflammatory peri-ileal and/or a perisigmoidal mass.In this study, we have sought to clarify the sequence of events by focusing on the segmental inflammation and the stricturing of the sigmoid so that its significance can be recognized as a local complication of the ileitis and the progression of its severity as opposed to arising sui generis., Materials and Methods: From our database of >3000 patients with inflammatory bowel disease at Lenox Hill Hospital, we identified 45 patients with Crohn's ileitis and ileosigmoid fistula (ISF): 24 had segmental sigmoid polyps and 18 had segmental inflammatory sigmoid strictures. The fistula was first seen by imaging in 36 patients, but not until resection by the surgeon or dissection by the pathologist in 7 patients., Results: The method of diagnosis for the initial recognition of the ISF and the sigmoid stricture is presented in Table 1. In 36 of the 45 cases, the ISF was recognized by radiologic imaging. In total, 31 of the 36 cases required surgical intervention, not because of the fistula, but because of small-bowel obstruction due to the ileitis. In 7 of the 31 (22%) cases, the fistula was recognized only by dissection of the inflammatory ileosigmoid mass by the surgeon or examination of the surgical specimen by the pathologist. The sequence of events from the originating ileitis to the ISF to the segmental sigmoid polyposis and stricture, with the resulting sigmoid obstruction, is shown in Figures 1A-E., Conclusions: We emphasize the natural history of the ISF so that its recognition will lead to earlier medical management of the originating ileitis. Furthermore, it adds evidence of the recognition that the causative agent of Crohn's disease is carried by the fecal stream.

We present an unusual and rare complication caused by gastric band erosion into the stomach after band placement 15 years ago. The complication was only picked up after the band had subsequently migrated from the stomach at the site of erosion, to the distal ileum causing acute small bowel obstruction and focal perforation requiring emergency laparotomy.Abdominal pain in patients with gastric band should always be treated as serious until proven otherwise., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

The majority of patients with Crohn's disease and up to 35 % of patients with ulcerative colitis will ultimately require surgery during the course of their disease. Over the past few years, surgical techniques and experience in minimal invasive surgery have evolved resulting in single-incision laparoscopic surgery. The aim of this approach is to diminish the surgical trauma by reducing the number of incision sites. This review discusses the benefits and disadvantages of single-port surgery in various procedures in patients with inflammatory bowel disease (IBD). Short-term postoperative results, functional outcome, and costs available in the literature will be discussed. Single-port surgery in IBD has several benefits when compared to multi-port laparoscopic surgery. By using fewer incisions, a potential reduction of postoperative pain with less morphine use can be accomplished. In addition, accelerated postoperative recovery can result in a shorter hospital stay. Furthermore, a superior cosmesis can be reached with placement of the port at the future ostomy site or at the umbilicus. Literature on single-port surgery in IBD consists mainly of case series and a few matched case series. These studies demonstrated that single-port surgery seems to be a safe and feasible approach for the surgical treatment of IBD patients.

Background: Actinomyces infection is a chronic inflammatory process that can sometimes, clinically and radiographically, closely mimic a malignant tumour, which may lead to giving a delayed or inappropriate treatment., Clinical Case: Male 41 years old, with no previous history, with abdominal pain of one month onset, as well as weight loss, intermittent fever and diarrhoea. He developed acute abdomen and underwent surgery, finding a tumour in the distal ileum with necrosis and punctiform perforations. A resection was performed on the affected part of the ileum and colon, as well as an ileostomy using Hartmann's procedure., Conclusions: Actinomycosis is a disease that must be considered by the surgeon when faced with a clinical picture of subacute onset with intermittent fever, weight loss, abdominal pain, and even anaemia in patients with abdominal and retroperitoneal abscesses or previous history of surgery., (Copyright © 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. All rights reserved.)

A middle-aged woman presented in shock with bleeding per rectum for 2 days without any significant past medical or surgical illness. Abdominal sonography, oesophagogastroduodenoscopy and sigmoidocolonoscopy were unremarkable. Despite 6 units of blood transfusion, 3000 mL of plasma expanders and ionotropes, the arterial pressure gradually decreased. We had no choice but to undergo life-threatening yet possibly life saving laparotomy. We found a 1×1 cm ileal bleeding mucosal polyp about 20 cm away from the ileocaecal junction. We resected and anastomosed end to end. Perioperatively, the patient was transfused with another 4 units of blood product. Immunohistopathology revealed a large number of CD34 positive spindle cells and eosinophils with extensive thick-walled capillaries compatible with inflammatory fibroid polyp. This case of Vanek's tumour is reported for its atypical site, which presented as massive obscure gastrointestinal haemorrhage without any prior warning signs., (2016 BMJ Publishing Group Ltd.)

Background and Aims: Post-operative recurrence is frequent in Crohn's disease. Genetic factors associated with post-operative recurrence remain poorly understood. Identification of genetic variants associated with repeat surgery would allow risk stratification of patients who may benefit from early aggressive therapy and/or post-operative prophylactic treatment., Methods: Crohn's disease patients who had at least one bowel resection were retrospectively identified from the "Nancy IBD cohort". Covariates and potential interactions were assessed using the Cox proportional hazard model. Kaplan-Meier curves for time to surgical recurrence were developed for 200 genetic variants and analyzed with the log-rank test., Results: 137 patients had at least 1 resection in our cohort: 38 had a surgical recurrence (28%). In multivariate analysis, current smoker status (OR 6.97, 95% CI 1.85-26.22, p=0.004), post-operative complications after prior surgery (OR 2.72, 95% CI 1.02-7.22, p=0.044), and Caspase recruitment domain-containing protein 8 (CARD8) homozygosity for the risk allele (OR 7.56, 95% CI 1.13-50.37, p=0.036) remained significantly and independently associated with surgical recurrence., Conclusion: Current smoker status was associated with increased risk of surgical recurrence. A novel association between CARD8 and increased risk of surgical recurrence in Crohn's disease was observed. CARD8 could be a new marker for risk stratification and prevention of recurrent surgery., (Copyright © 2015 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Few data are available regarding emergency surgery for Crohn's disease (CD) during pregnancy. A 22-year -old woman, at 26 weeks of pregnancy, was admitted for premature labour, intestinal obstruction and systemic inflammation. Biology and ultrasonography were not helpful; imaging was completed with a CT scan, which confirmed the mechanical ileal obstruction. The intestinal obstruction worsened and led to emergency surgery. An inflammatory stenosis of the terminal ileum with two fistulas was found. An ileal resection and ileostomy were performed. The pathological analysis of the resected specimen confirmed CD. The postoperative course was uneventful. The delivery of a baby with normal weight and status occurred at term (40 weeks of amenorrhoea). There have been only 10 case reports of intestinal complications revealing CD during pregnancy. The delay in diagnosis and adequate treatment led to significant maternal and fetal morbidity and mortality. This case suggests that intestinal surgery for CD is feasible during pregnancy and may be associated with a favourable outcome for the baby as well as for the mother., (2015 BMJ Publishing Group Ltd.)

Background: Factors influencing recurrence of ileocecal Crohn's disease (CD) after surgical resection may differ between adolescents and adults., Methods: CD patients who underwent ileocecectomy were retrospectively divided into pediatric onset (age at diagnosis ≤ 16 years, n = 34) and adult onset (>16, n = 108) patients to evaluate differences in risks of endoscopic and clinical recurrence., Results: In 142 patients, rates of any recurrence, endoscopic recurrence, and clinical recurrence at 5 years were 78%, 88%, and 65%, respectively. Risks of recurrence were similar between groups. Younger patients were more likely to be on immunologics preoperatively and more likely to be started on immunoprophylaxis postoperatively. Immediate postoperative prophylaxis was predictive of delayed clinical recurrence only in the older group., Conclusions: Despite increased preoperative and postoperative immunoprophylaxis in younger patients, recurrence rates of CD after ileocecectomy do not differ between these groups. Immediate postoperative prophylaxis was predictive of delayed clinical recurrence only in patients with adult onset CD., (Copyright © 2014 Elsevier Inc. All rights reserved.)

A 65-year-old woman was admitted with sudden-onset abdominal pain. Abdominal computed tomography revealed hepatic portal venous gas. Physical and laboratory examination suggested that a conservative approach was appropriate; however, 4 days later, the pain recurred and severe ischemic enteritis was diagnosed. A stenosis was identified 60 cm distal to the start of the ileum, and partial resection of the small intestine was performed. The diagnosis of ischemic enteritis was confirmed. Ischemic enteritis affecting the small intestine is uncommon, and enteritis causing intestinal stenosis with hepatic portal vein gas is even rarer.

Background and Aims: As a part of the Swedish ICURE study where the epidemiological results of ulcerative colitis and microscopic colitis recently have been published, we hereby present the corresponding figures for Crohn's disease., Methods: All patients diagnosed with Crohn's disease in Uppsala County (305,381 inhabitants) were prospectively registered during 2005-2006 and the same for all new patients with Crohn's disease in Uppsala Region (642,117 inhabitants) during 2007-2009., Results: 264 patients with Crohn's disease were included. The mean annual incidence was 9.9/100,000/year (95% CI: 7.1-12.6). Incidence among children <17 years was 10.0/100,000/year (95% CI: 3.8-16.3). 51% of the patients had ileal involvement (L1: n=73, 28%. L2: n=129, 49%. L3: n=62, 23%, L4: n=47, 18%) and 23% had a stricturing or penetrating disease (B1: n=204, 77%. B2: n=34, 13%. B3: n=26, 10%. p: n=27, 10%). Intestinal resection rate during the first year was 12.5%. Patients with complicated disease had longer symptom duration before diagnosis compared to patients with non-complicated disease (median months 12.0, IQR: 3.0-24.0 vs 4.0, IQR: 2.0-12.0, p=0.0032). Patients 40 years or older had an increased risk for surgery (HR: 2.03, 95% CI: 1.01-4.08, p=0.0457)., Conclusions: The incidence of Crohn's disease in a region of Sweden is one of the highest reported in Europe. Long symptom duration precedes stricturing or penetrating behaviour. Old age is an independent risk factor for surgery., (© 2013.)

Objectives: In classifying Crohn's disease (CD) location, proximal (L4) disease includes esophagogastroduodenal (EGD) and jejunal disease. Our aim was to determine the influence of proximal disease on outcomes of behavior and need for surgery and to determine if there was significant clinical heterogeneity between EGD and jejunal disease., Methods: We performed a cross-sectional query of the NIDDK (National Institute of Diabetes and Digestive and Kidney Disease) Inflammatory Bowel Disease Genetics Consortium (IBDGC) database of patients with a confirmed diagnosis of CD and phenotyped per the IBDGC manual. Presence of any L4, L4-EGD, L4-jejunal, and non-L4 disease (L1-ileal, L2-colonic, and L3-ileocolonic) was compared with demographic features including age, race, ethnicity, smoking and inflammatory bowel disease (IBD) family history, diagnosis age, disease duration, clinical outcomes of inflammatory, stricturing or penetrating behavior, and CD abdominal surgeries. Univariate and multivariable analyses were performed with R., Results: Among 2,105 patients with complete disease location data, 346 had L4 disease (175 L4-EGD, 115 L4-jejunal, and 56 EGD and jejunal) with 321 having concurrent L1-L3 disease. In all, 1,759 had only L1-L3 disease. L4 vs. non-L4 patients were more likely (P<0.001) to be younger at diagnosis, non-smokers, have coexisting ileal involvement, and have stricturing disease. L4-jejunal vs. L4-EGD patients were at least twice as likely (P<0.001) to have had ileal disease, stricturing behavior, and any or multiple abdominal surgeries. Remarkably, L4-jejunal patients had more (P<0.001) stricturing behavior and multiple abdominal surgeries than non-L4 ileal disease patients. Logistic regression showed stricturing risks were ileal (without proximal) site (odds ratio (OR) 3.18; 95% confidence interval 2.23-4.64), longer disease duration (OR 1.33/decade; 1.19-1.49), jejunal site (OR 2.90; 1.89-4.45), and older age at diagnosis (OR 1.21/decade; 1.10-1.34). Multiple surgery risks were disease duration (OR 3.74/decade; 3.05-4.64), penetrating disease (OR 2.60; 1.64-4.21), and jejunal site (OR 2.39; 1.36-4.20), with short duration from diagnosis to first surgery protective (OR 0.87/decade to first surgery; 0.84-0.90)., Conclusions: Jejunal disease is a significantly greater risk factor for stricturing disease and multiple abdominal surgeries than either EGD or ileal (without proximal) disease. The Montreal site classification should be revised to include separate designations for jejunal and EGD disease.

Aim: To give an overview of the literature on intussusception due to inflammatory fibroid polyp (IFP)., Methods: We present a new case of ileal intussusception due to IFP and a literature review of studies published in English language on intussusception due to IFP, accessed via PubMed and Google Scholar databases. For the search, the keywords used were: intussusception, IFP, intussusception and IFP, intussusception due to IFP, and IFP presenting as intussusception. The search covered all articles from 1976 to November 2011., Results: We present a 38-year-old woman who was admitted 10 d after experiencing abdominal pain, vomiting, and nausea. Ultrasonography demonstrated small bowel intussusception. An ileal intussusception due to a mass lesion 50 cm proximal to the ileocecal junction was found during laparotomy. Partial ileal resection and anastomosis were performed. A diagnosis of ileal IFP was made based on the immunohistochemical findings. In addition, a total of 56 reports concerning 85 cases of intussusception due to IFP meeting the aforementioned criteria was included in the literature review. The patients were aged 4 to 81 years (mean, 49 ± 16.2 years); 44 were women (mean, 51.8 ± 14.3 years) and 41 were men (mean, 46 ± 17.5 years). According to the location of the IFP, ileal intussusception was found in 63 patients, while 17 had jejunal, three had colonic, and two had ileojejunal intussusception., Conclusion: Although IFPs are rare and benign, surgery is the only solution in case of intestinal obstruction. Differential diagnosis should be made via immunohistochemical examination.

Cryptogenic multifocal ulcerous stenosing enteritis is a rare idiopathic disease of the small bowel. Its origin and pathophysiology have not been established. Clinicopathologic features include unexplained small bowel strictures with superficial ulceration, chronic or relapsing occlusion episodes. A 44-year-old man complained of recurrent colicky abdominal pain and dizziness. Laboratory tests indicated iron-deficiency anemia. There was no evidence of bleeding on esophagogastroduodenoscopic and colonofiberscopic examination. With capsule endoscopy, multiple mucosal ulcers were visualized in the jejunoileal area. A small-bowel series revealed severe strictures and the capsule was retained in the stenotic focus without obstructive symptoms. Small bowel segmental resection with end-to-end anastomosis was performed, and the histologic examination indicated cryptogenic multifocal ulcerous stenosing enteritis. After surgery, the patient's symptoms were completely resolved and his anemia was corrected. Cryptogenic multifocal ulcerous stenosing enteritis should be considered in cases of chronic or recurrent occlusion events and multiple small intestinal ulcers and strictures of unknown origin.

In chronic inflammatory states, the ileal mucosa may flatten, whereas the colonic mucosa may develop a villiform surface. Accordingly, pathologic biopsies labeled by the endoscopist as "ileocolic" or "ileocecal" may generate confusion or uncertainty as to their specific origin. To facilitate distinguishing between architecturally altered ileal and colonic mucosae, we assessed the hepatocyte paraffin 1 (Hep Par 1) antibody, reported to react with normal and metaplastic small bowel epithelium but not with normal colonic epithelium, in 25 ileal biopsies (10 normal and 15 pathologic), 25 colonic biopsies (10 normal and 15 pathologic), and 20 samples labeled as "ileocecal" or "ileocolic" in which the organ of origin could not be definitely established because of mucosal inflammation and distortion. The latter group included 8 cases diagnosed as being of "probable ileal origin," 7 cases diagnosed as being of "probable colonic origin," and 5 cases diagnosed as "uncertain." Diffuse granular cytoplasmic Hep Par 1 expression was detected in all normal and pathologic ileal mucosal biopsies, whereas all colonic biopsies were negative or focally reactive. Cases of "probable ileal origin" were diffusely positive (granular cytoplasmic pattern), whereas those of "probable colonic origin" were negative or focally reactive. Two of the "uncertain" cases expressed Hep Par 1, whereas 3 were negative, thus supporting their ileal and colonic derivation, respectively. In conclusion, Hep Par 1 is diffusely expressed by pathologic ileal mucosa, being negative or only focally positive in pathologic colonic mucosa. Accordingly, it represents a valuable tool for recognizing the tissue source in problematic ileocolonoscopic biopsies.

Background: The aim of this study was to assess the accuracy of preoperative imaging in detecting the extent of disease and predicting the operative approach in patients with Crohn's disease., Methods: Patients with Crohn's disease who were scheduled to undergo operation were evaluated before operation using computed tomography enteroclysis (CTE) and magnetic resonance enterography (MRE). Preoperative imaging findings were correlated with intraoperative and pathological findings to estimate the capabilities of preoperative imaging in detecting lesions due to Crohn's disease. The operative approach determined before surgery was compared with the procedure actually performed, which was based on intraoperative findings., Results: Fifty-two patients with Crohn's disease were studied; 26 were evaluated before surgery with CTE and 26 with MRE. Eighty-nine lesions due to Crohn's disease were confirmed surgically (60 small bowel stenoses, 21 fistulas and 8 abscesses). CTE confirmed the presence of 38 of 41 lesions (sensitivity 93 per cent) and MRE 48 of 48 lesions (sensitivity 100 per cent); a correct estimation of the disease with an exact prediction of the operative approach was obtained in 49 (94 per cent) of 52 patients. Discrepant findings between preoperative imaging and operative findings were observed in three patients (6 per cent), who had CTE., Conclusion: Preoperative imaging using CTE or MRE is highly accurate for assessing Crohn's disease lesions before operation, allowing correct prediction of the operative approach., (Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Background: Inflammatory fibroid polyps (IFPs) are rare benign lesions of uncertain origin that may occur in various parts of the gastrointestinal tract that originate from the sub mucosa located in different sites of the digestive tract. They are commonly located in the stomach and small bowel. It is one of the probable diagnoses that should be considered in obstructive tumors of the small intestine causing invagination., Methods: A case of IFP is presented, causing intestinal invagination in an 39-year-old female patient, admitted with abdominal distension and pain., Result: Computerised tomography imaging (CT) demonstrated intussusception of the small bowel. Exploratory laparotomy revealed a bowel intussusception. An ileo-ileal anastomosis was performed after resection of the tumoral segment. Histology of the resected small bowel revealed an inflammatory fibroid polyp., Conclusions: intussusception secondary to IFPs of the small intestine are difficult to diagnose without recognition of its clinical and pathological characteristics. CT is useful in confirming an anatomical abnormality, histological examination establishes the final diagnosis of IFPs.

Background: The role of single-site laparoscopy (SSL) for the treatment of ileocolic Crohn's disease complicated by an abscess, a phlegmon, or fistulizing disease has not been thoroughly assessed., Methods: A prospectively maintained database of SSL surgeries performed between October 2010 and March 2011 was reviewed. Consecutive patients with ileocolic Crohn's disease complicated by a paracolic abscess, a phlegmon, or a fistula were included for analysis. Data recorded included demographic information, body mass index (BMI), estimated blood loss (EBL), length of surgery, rate of conversion to standard laparoscopic surgery or open surgery, length of hospital stay, and rate of complications., Results: A total of six patients were identified. Complications from Crohn's disease included four (66%) patients who developed a paracolic abscess that required drainage upon admission, one (16%) patient who developed a phlegmon, and one (16%) patient who developed an enterocutaneous fistula. Mean age of the study population was 25 years, with a mean BMI of 21 and a mean ASA score of 3. Five (83%) of the patients were immunosuppressed with high-dose steroids. Mean operative time was 160 min, with a median EBL of 60 mL. One patient required the insertion of an additional trocar, whereas there were no conversions to laparotomy. Four (66%) patients required diversion with a loop ileostomy. Median time to flatus was 1 day. All patients tolerated a diet on the day of surgery, with a median length of stay of 3 days. There were no deaths and no complications related to bleeding, organ injury, surgical site infections, or anastomotic leaks., Conclusions: A single-site laparoscopic approach for complicated ileocolic Crohn's disease can be performed safely, with short lengths of hospital stay and with a low rate of complications. A multicenter study would be beneficial to validate these findings.

Background: Single-incision laparoscopic surgery is a development in the field of minimally invasive surgery that is being increasingly used for colorectal procedures., Objective: We report on the short-term results of single-port laparoscopic ileocolic resection in patients with ileocecal Crohn's disease., Design: This investigation is a retrospective matched-pair control study. Data were obtained from a prospectively maintained single-institution inflammatory bowel disease database., Settings: This study was conducted at a tertiary care university hospital., Patients: Twenty consecutive patients receiving elective single-port ileocolic resection between April 2010 and May 2011 were included (6 male, 14 female; age, 31.6 ± 10.8 years; BMI, 21.5 ± 2.6 kg/m). Their data were compared with the data of 20 individually matched patients who had undergone standard 3-trocar laparoscopic-assisted ileocolic resection between 2007 and 2010 (6 male, 14 female; age, 31.7 ± 10.7 years; BMI, 21.2 ± 2.5 kg/m). All patients had medically refractory stenosis of the terminal ileum in histologically confirmed Crohn's disease., Interventions: Single-port laparoscopic-assisted or standard laparoscopic-assisted ileocolic resection was performed., Main Outcome Measures: The primary outcomes measured were the surgical details and early outcome., Results: : The mean length of the paraumbilical single-port incision was 3.8 cm (range, 2.5-5.0 cm). Conversion rates were similar in both groups (1/20 vs 2/20, p = 0.55). Additional strictureplasties or short-segment small-bowel resections were performed in both groups. The overall complication rate was 20% (4/20) in both groups. There were no observed differences in postoperative pain scores and hospital stay duration., Limitations: The limitations of this study were as follows: this study was a comparison of 2 different time points with possible selection bias, there was no prestudy power calculation, and the study might be underpowered., Conclusions: Single-port ileocolic resection is a safe procedure for the surgical treatment of stenotizing Crohn's disease of the terminal ileum. Avoidance of additional trocars was the only identified benefit.

Cysteine is considered as a conditionally indispensable amino acid. Its dietary supply should thus be increased when endogenous synthesis cannot meet metabolic need, such as during inflammatory diseases. However, studies in animal models suggest a high first-pass extraction of dietary cysteine by the intestine, limiting the interest for an oral supplementation. We investigated here unidirectional fluxes of cysteine across the portal-drained viscera (PDV) of multi-catheterized minipigs, using simultaneous intragastric L-[(15)N] cysteine and intravenous L-[3,3D2] cysteine continuous infusions. We showed that in minipigs fed with an elemental enteral solution, cysteine first-pass extraction by the intestine is about 60% of the dietary supply, and that the PDV does not capture arterial cysteine. Beside dietary cysteine, the PDV release non-dietary cysteine (20% of the total cysteine release), which originates either from tissue metabolism or from reabsorption of endogenous secretion, such as glutathione (GSH) biliary excretion. Experimental ileitis induced by local administration of trinitrobenzene sulfonic acid, increased liver and ileal GSH fractional synthesis rate during the acute phase of inflammation, and increased whole body flux of cysteine. However, cysteine uptake and release by the PDV were not affected by ileitis, suggesting an adaptation of the intestinal sulfur amino acid metabolism in order to cover the additional requirement of cysteine linked to the increased GSH synthesis. We conclude that the small intestine sequesters large amounts of dietary cysteine during absorption, limiting its release into the bloodstream, and that the other tissues of the PDV (colon, stomach, pancreas, spleen) preferentially use circulating methionine or cysteine-containing peptides to cover their cysteine requirement.

Background: A perforating phenotype is associated with an increased postoperative morbidity in patients with Crohn's disease undergoing ileocolic resection. Sequential conservative treatment attempts applied to patients with unrecognized perforating complications may lead to a delay of surgery and a further increase in morbidity., Methods: In all, 197 patients underwent 231 bowel resections for perforating ileitis between 1992 and 2009. The duration or clinical deterioration was calculated from the onset of clinical exacerbation unresponsive to any medical treatment to the date of surgery., Results: The median duration of clinical deterioration leading to surgery was 5 months. Patients with preoperative exacerbation lasting for >5 months had a higher number of structures involved in the inflammatory mass (3.3 versus 2.8 structures, P = 0.013), and had a higher probability to take immunosuppressive drugs (26% versus 14%, P = 0.042), budesonide (29% versus 14%, P = 0.009), and a multiple-drug combination (31% versus 16%, P = 0.015) at the time of surgery. Patients with symptoms lasting >5 months prior to surgery had a higher incidence of postoperative septic complications (31% versus 13%, P = 0.002), both by univariate and multivariate analysis. There was a significant increase in duration of preoperative clinical deterioration, size of the inflammatory mass, incidence of preoperative weight loss, intake of immunosuppressants and multiple-drug combination, and postoperative morbidity during the last 5 years of the study., Conclusions: Delay of surgery in patients presenting with symptoms attributable to perforating ileitis is associated with an increased postoperative risk., (Copyright © 2010 Crohn's & Colitis Foundation of America, Inc.)

Background: The aim of the present study was to evaluate strictureplasty as the first choice for surgical treatment for Crohn's terminal ileitis., Methods: Between 1996 and 2000 we performed Finney-shaped ileocecal strictureplasty (ICS), doubling up the diseased terminal ileum, in 14 patients affected by Crohn's disease (group A). We compared the postoperative and long-term outcomes of these patients with those of 14 similar patients who underwent ileocecal resection with ileocolonic anastomosis during the same period (group B)., Results: No postoperative morbidity or mortality was recorded in group A, whereas two patients of group B had a pelvic hematoma and cholestatic hepatopathy, respectively. The mean hospital stay after surgery was 9.9 days (range 7-13 days) in group A and 7.4 days (range 6-10 days) in group B. After a median follow-up of 120 months (range 103-147 months), five patients of group A had a symptomatic recurrence: A stricture at the site of the ICS was present in four of them, but only one required surgery; symptoms were controlled by medical therapy in the other three. The fifth symptomatic patient was reoperated for multiple jejunoileal recurrence of the disease above the ICS. Group B patients have been followed for a mean of 108 months (range 90-140 months). Four of the patients had a preanastomotic recurrence, with subocclusive symptoms and mild malnutrition treated with medical therapy., Conclusions: Our results indicate that there are no significant differences between ICS and resection in terms of outcome and clinical relapse of Crohn's terminal ileitis.

A young man with known steroid refractory terminal ileal Crohn's disease developed torrential gastrointestinal bleeding necessitating an emergency ileal resection. Serology was indicative of primary cytomegalovirus (CMV) infection and this was confirmed with histopathology of the resected ileum. We highlight the difficulty in clinical practice of distinguishing between CMV infection and CMV disease as well as the different investigations available to aid in the diagnosis of pathogenic CMV disease., (© 2010 The Authors. Internal Medicine Journal © 2010 Royal Australasian College of Physicians.)

Purpose: The outcome of ileal pouch-anal anastomosis in patients with backwash ileitis is controversial. We prospectively compared the outcomes of ileal pouch-anal anastomosis in colitis patients with backwash ileitis and colitis patients without backwash ileitis., Methods: Consecutive colitis patients undergoing ileal pouch-anal anastomosis were reviewed. All patients were classified after surgery as being either backwash ileitis-positive or backwash ileitis-negative. Serum drawn preoperatively was assayed, using enzyme-linked immunosorbent assay, for anti-Saccharomyces cerevisiae, anti-outer membrane of porin C, anti-CBir1, anti-I2, and perinuclear anti-neutrophil cytoplasmic antibody. Outcomes included acute pouchitis (antibiotic responsive), chronic pouchitis (antibiotic dependent or refractory), or de novo Crohn's disease (small inflammation above the pouch inlet or pouch fistula)., Results: Out of 334 patients, 39 (12%) were backwash ileitis-positive. Compared with backwash ileitis-negative patients, backwash ileitis-positive patients had a higher incidence of pancolitis (100% vs 74%; P = .0001), primary sclerosing cholangitis (15% vs 2%; P = .001) and high-level (>100 enzyme-linked immunosorbent assay units/ml) perinuclear anti-neutrophil cytoplasmic antibody expression (29% vs 9%; P = .001). After a median follow-up of 26 months, 53 patients (16%) developed acute pouchitis, 37 (11%) developed chronic pouchitis, and 40 (12%) developed de novo Crohn's disease. There was no significant difference between the backwash ileitis-positive and backwash ileitis-negative patient groups in the incidence of acute pouchitis, chronic pouchitis, or de novo Crohn's disease., Conclusion: There was a significantly higher incidence of pancolitis, primary sclerosing cholangitis, and high-level perinuclear anti-neutrophil cytoplasmic antibody expression in backwash ileitis-positive patients than in backwash ileitis-negative patients. The incidence of acute pouchitis, chronic pouchitis, and de novo Crohn's disease after ileal pouch-anal anastomosis does not differ significantly between backwash ileitis-positive and backwash ileitis-negative patients.

Background: A pressing need exists to identify factors that predispose to recurrence after terminal ileal resection for Crohn's disease (CD) and to determine effective prophylactic strategies. This review presents an up-to-date summary of the literature in the field and points to a role for bacterial overproliferation in recurrence., Methods: The literature (Medline, Embase, and the Cochrane Library, 1971-2009) on ileal CD and postoperative recurrence was searched, and 528 relevant articles were identified and reviewed., Results: Smoking is a key independent risk factor for recurrence. NOD2/CARD15 polymorphisms and penetrating phenotype are associated with aggressive disease and higher reoperation rates. Age at diagnosis, disease duration, gender, and family history are inconsistent predictors of recurrence. Prophylactic 5-aminosalicylic acid therapy and nitromidazole antibiotics are beneficial. Combination therapies with immunosuppressants are also effective. Anti-TNFalpha-based regimens show benefit but the evidence base is small. Corticosteroid, interleukin-10, and probiotic therapies are not effective. Wider, stapled anastomotic configurations are associated with reduced recurrence rates. Strictureplasty and laparoscopic approaches have similar long-term recurrence rates to open resection techniques. Length of resection and presence of microscopic disease at resection margins do not influence recurrence. A lack of consensus exists regarding whether the presence of granulomas or plexitis affects outcome., Conclusions: Current evidence points to defects in mucosal immunity and intestinal dysbiosis of either innate (NOD2/CARD15) or induced (smoking) origin in postoperative CD recurrence. Prophylactic strategies should aim to limit dysbiosis (antibiotics, side-to-side anastomoses) or prevent downstream chronic inflammatory sequelae (anti-inflammatory, immunosuppressive, and immunomodulatory therapy).

Background: Ileocolic resection for Crohn's disease can be performed entirely laparoscopically. However, an incision is needed for specimen extraction. This prospective observational study assessed the feasibility of endoscopic transcolonic specimen removal., Methods: Endoscopic specimen removal was attempted in a consecutive series of ten patients scheduled for laparoscopic ileocolic resection. Primary outcomes were feasibility, operating time, reoperation rate, pain scores, morphine requirement and hospital stay. To assess applicability, outcomes were compared with previous data from patients who had laparoscopically assisted operations., Results: Transcolonic removal was successful in eight of ten patients; it was considered not feasible in two patients because the inflammatory mass was too large (7-8 cm). Median operating time was 208 min and median postoperative hospital stay was 5 days. After surgery two patients developed an intra-abdominal abscess, drained laparoscopically or percutaneously, and one patient had another site-specific infection. The operation took longer than conventional laparoscopy, with no benefits perceived by patients in terms of cosmesis or body image., Conclusion: Transcolonic removal of the specimen in ileocolic Crohn's disease is feasible in the absence of a large inflammatory mass but infection may be a problem. It is unclear whether the technique offers benefit compared with conventional laparoscopic surgery., (Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Objectives: To define risk factors for recurrence and to determine whether postoperative prophylaxis would influence time to recurrence after primary laparoscopic ileocolectomy for Crohn disease., Design: Retrospective record review., Setting: Tertiary academic medical center., Patients: All patients who underwent primary laparoscopic ileocolectomy for terminal ileal Crohn disease between April 28, 1994, and August 3, 2006, at the Mayo Clinic, Rochester, Minnesota., Main Outcome Measures: All patients were reviewed for follow-up, recurrence, risk factors for recurrence, and use of postoperative immunosuppressive prophylaxis., Results: One hundred nine patients were identified, of whom 89 were followed up postoperatively at Mayo Clinic with a median follow-up of 3.5 years (range, 1.8 months to 11.9 years). Recurrence was discovered in 54 patients (61%) at a median of 13.1 months (range, 1.3 months to 8.7 years). Forty-four patients (49%) received postoperative immunosuppressive prophylaxis (37 [42%] received azathioprine, 8 [9%] received 6-mercaptopurine, and 3 [3%] received infliximab). In a multivariate model of various risk factors for recurrence, presence of granulomas was the only significant predictor of recurrence (P = .01). The 2-year cumulative recurrence rates in the prophylaxis and nonprophylaxis groups were 37.5% and 52.6%, respectively (log-rank test, P = .87)., Conclusions: Recurrence occurred in more than half of the patients with Crohn disease after primary laparoscopic ileocolectomy. In this highly selected patient population, use of immunosuppressive prophylaxis was not associated with a delay in recurrence. Presence of granulomas was the only significant predictor of recurrence. These findings should be further explored in larger and less selected patient populations.