The Predictive Value of Inflammation at Ileocecal Resection Margins for Postoperative Crohn’s Recurrence: A Cohort Study

Abstract

Background Resections for Crohn’s disease should be limited and only resect macroscopically affected bowel. However, recent studies suggest microscopic inflammation at resection margins as a predictor for postoperative recurrence. The clinical impact remains unclear, as non-uniform pathological criteria have been used. The aim of this study was to assess the predictive value of pathological characteristics at ileocecal resection margins for recurrence. Methods Both resection margins of 106 consecutive patients undergoing ileocecal resection for Crohn’s disease between 2002 and 2009 were revised and scored for active inflammation, myenteric plexitis, and granulomas. Pathological findings were correlated to recurrence, defined as recurrent disease activity demonstrated by endoscopy (modified Rutgeerts score ≥i2) requiring upscaling medical treatment, using multivariate analysis. Results Active inflammation was found at the proximal and distal resection margin in 27% and 15% of patients, respectively, myenteric plexitis in 37% and 32%, respectively, and granulomas in 4% and 6%, respectively. In total, 47 out of 106 patients developed recurrence. Only active inflammation at the distal colonic resection margin was an independent significant predictor for recurrence (88% vs 43% vs 51% for distal, proximal, and no involved margins, respectively; P < 0.01). Conclusion Active inflammation at the distal colonic resection margin after ileocecal resection identifies a patient group at high risk for postoperative recurrence both at the anastomotic site and the colon because it identifies undiagnosed L3 disease. These patients have a different and more aggressive natural history and require more intense medical treatment. Therefore, pathological evaluation of the distal resection margin should be implemented in daily practice.

Anatomical Variation in Mesenteric Macrophage Phenotypes in Crohn's Disease

“…This subgroup analysis revealed that the mesentery of patients with L3 disease contained more unfavorable proinflammatory macrophages at the “central” and “resection margin” sites (Figure 2 a). This suggests that patients with L3 disease have widespread localization of proinflammatory macrophages in the mesentery, in line with the previous finding that these patients have higher recurrence rates ( 23 ). Interestingly, in our cohort, recurrence (defined as a Rutgeerts score ≥ i2b, 6 months after surgery) was associated with the presence of proinflammatory macrophages in the mesentery at the resection margin (Figure 2 b).…”

The Revival of Surgery in Crohn’s Disease—Early Intestinal Resection as a Reasonable Alternative in Localized Ileitis

“…[81] This is underlined by a multicenter study which demonstrated that a transmural lesion, especially at the oral resection margin, is independently associated with an increased risk for postoperative recurrence (75% versus 46%) [82]. Interestingly, Wasman et al demonstrated in more detail that patients with active inflammation at the colonic resection margin after ICR might have a different and more aggressive disease and might require more intense medical treatment [83]. Furthermore, two recent meta-analyses demonstrated that histological positive resection margins increased clinical and surgical recurrence with a trend towards endoscopic recurrence but definitions of margin positivity and postoperative recurrence varied throughout the studies and limited the final conclusion [78,79].…”

How to Manage Crohn’s Disease After Ileocolonic Resection?

“…14 Other relevant risk factors include prior resections, fistulizing/ penetrating disease as surgical indication, extensive bowel disease (> 50 cm), upper gastrointestinal involvement, male gender, granulomas in the resection specimen, histological inflammation at the ileal and possibly colonic margins. [15][16][17][18][19][20] Myenteric plexitis has not been reproduced as a risk factor. [15][16][17][18][19][20][21] So far, no genetic factors have been identified.…”

“…[15][16][17][18][19][20] Myenteric plexitis has not been reproduced as a risk factor. [15][16][17][18][19][20][21] So far, no genetic factors have been identified. At the level of the microbiome, lack of significant concentrations of Faecalibacterium prausnitzii in the ileal mucosa has been associated with higher recurrence rates.…”