The Portsmouth protocol for intra‐operative ultrasound of the small bowel in Crohn's disease

Abstract

Aim Bowel preservation is paramount in Crohn's disease surgery as affected patients are typically young adults at risk of having several abdominal surgical procedures during their lifetime. Intra‐operative assessment of the extent and location of Crohn's disease is not standardized and is left to a mixture of the surgeon's experience, tactile feedback, macroscopic appearance and preoperative imaging. The aim of this study was to describe the technical steps of a standardized protocol for intra‐operative ultrasound assessment of the small bowel in patients undergoing surgery for ileocolic Crohn's disease. Method After laparoscopic mobilization of the bowel, a periumbilical incision is performed for extracorporeal division of the mesentery and the resection and anastomosis. A gastrointestinal consultant radiologist, with expertise in Crohn's disease imaging and abdominal ultrasound, performs full intra‐operative assessment of the small bowel by applying a sterile ultrasound probe directly to the bowel, prior to resection being performed by the surgeon. The bowel is assessed through the wound protector with a sterile technique and the length, location and number of segments is documented together with further quantitative assessment using the METRIC (MR enterography or ultrasound in Crohn's disease) scoring guide. Results A step‐by‐step protocol for intra‐operative ultrasound evaluation of the entire small bowel is described. Conclusions A standardized approach to intra‐operative evaluation of the extent and location of Crohn's disease is desirable. Intra‐operative ultrasound may provide added value for assessment of proximal and multifocal Crohn's disease.

Feasibility of intraoperative ultrasound of the small bowel during Crohn’s disease surgery

“…We included patients with CD affecting the small bowel requiring elective surgical treatment, according to the following inclusion criteria: (1) Aged 18 years or over; (2) American Society of Anaesthesiologists (ASA) grade I, II or III; (3) Undergoing elective surgery to remove part of the terminal ileum which is affected by CD; (4) Indication for surgery agreed at inflammatory bowel disease (IBD) multidisciplinary team (MDT) meeting; (5) Able to give written informed consent.…”

“…Moreover, incorrect intraoperative mapping of the extent of disease may mislead the multidisciplinary team in decision making about postoperative maintenance treatment. To overcome this variability, we developed a protocol for full intraoperative ultrasound scan (USS) of the small bowel [2]. The aim of this study was to report the results of the feasibility study "Assessing the Feasibility and Safety of Using Intraoperative Ultrasound in Ileocolic Crohn's Disease-The IUSS CROHN Study".…”

Preoperative assessment of skeletal muscle mass during magnetic resonance enterography in patients with Crohn’s disease

“…In our IBD Unit we are currently developing a prospective study with focus on MRE defined sarcopenia and functional assessment of muscle function, also including a psoas muscle assessment at intestinal USS as part of an experimental pre and intraoperative dedicated USS protocol. [ 47 ].…”

Localization of recurrent lesions following ileocolic resection for Crohn's disease

“…In the future, an intraoperative lesion search will also require technological progress without relying on the experience and inspection ability of the attending surgeon. In this regard, Celentano V et al reported the usefulness of an intraoperative ultrasound examination of the small bowel in Crohn's disease patients [9].…”