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Background
Assessment of the entire small bowel is advocated during Crohn’s disease (CD) surgery, as intraoperative detection of new lesions may lead to change in the planned procedure. The aim of this study was to evaluate the inter-observer variability in the assessment of extent and severity of CD at the small bowel laparoscopic “walkthrough”.Me...
Citations
... Some mesenteric characteristics have been proposed to be linked with intraoperative complications and long-term surgical recurrence (Appendix B), and a mesenteric disease activity index has been proposed [3]. Ensuring standardised annotation and classification of the mesenteric disease could help reduce interobserver differences and blind re-evaluation when necessary [13]. ...
Background:
There are reported variations in the intraoperative management of Crohn's disease. The aim of this consensus statement is to develop a standardised protocol for photographic documentation of intraoperative findings and critical procedural steps in ileocolonic Crohn's disease surgery.
Methods:
Colorectal surgeons with a specialist interest in minimally invasive surgery and Inflammatory Bowel Disease were invited as committee members to develop a survey on the use of photo-documentation in Crohn's disease surgery. A 15 items survey was developed on ethical considerations and applications of photo-documentation in audit and quality control, research, and training.
Results:
There was strong agreement on the potential application of intraoperative photo-documentation in Crohn's disease for training, research, quality control and tertiary referrals. Reviewers agreed that intra-operative staging required photo-documentation of strictures, skip lesions, perforations, fat wrapping and mesenteric disease. The necessary steps to be photo-documented were very specific to Crohn's disease surgery, such as views of anastomosis and strictureplasties, and extent of resection(s).
Conclusions:
Our consensus statement identifies several items for appropriate intraoperative photo-documentation in Crohn's disease surgery, to be used as an adjunct to accurate annotation of intraoperative findings and procedures.
... The full videos were edited and anonymized to demonstrate 4 specific steps of the surgical procedure 16 ; mobilization and division of the rectum, formation of the ileoanal J-pouch reservoir, anastomosis, and lengthening techniques. ...
Background
Ileal pouch anal anastomosis is a complex procedure associated with significant morbidity, with several complications after ileal pouch anal anastomosis surgery leading to pouch failure. The aim of the study is to evaluate the heterogeneity surrounding the technique of ileoanal J-pouch surgery by assessing the safety and quality of published online peer-reviewed surgical videos.
Methods
Ileal pouch anal anastomosis videos published on peer-reviewed surgical journals and video channels were edited and anonymized to demonstrate specific steps of the surgical procedure: mobilization and division of the rectum, formation of the ileoanal J-pouch reservoir, anastomosis, and lengthening techniques. The anonymized videos were presented to a group of reviewers with expertise in ileal pouch anal anastomosis blinded to the names and affiliations of the surgeons performing the procedure. Primary outcome was the rate of interobserver variability in the assessment of specific technical steps of the ileal pouch anal anastomosis surgery procedure. Secondary outcome was the appropriateness of the use of surgical videos review as an assessment tool for ileal pouch anal anastomosis surgery, measured as rate of reviewers being unable to answer for poor video quality.
Results
In total, 29 video fragments were distributed, and 13 assessors completed a 60-item survey, organized in 7 major domains. The survey completion rate was 93.4%. Out of a total 729 answers, in 23 (3.2%) the reviewers indicated they were unable to comment due to poor video image, and in 48 (6.5%) were unable to comment due to the particular step not being shown in the procedure. The proportion of assessors rating rectal mobilization technically appropriate ranged from 30.7% to 92.3% and from 7.7% to 69.2% for safety. The level of rectal division was considered appropriate in 0 to 53.8% of the videos, whereas the stapling technique used for rectal division was appropriate in 0 to 70% of the videos.
Conclusion
Our study assessed published peer-reviewed videos on ileal pouch anal anastomosis surgery and reported heterogeneity in the safety of the demonstrated techniques. Blind assessment of published peer-reviewed ileal pouch anal anastomosis videos reported a high rate of unsafe or inappropriate technique for rectal mobilization and transection in the reviewed videos, with fair interobserver agreement among reviewers. There is a need for consensus on what is considered safe and appropriate in ileal pouch anal anastomosis surgery. Peer review of ileal pouch anal anastomosis surgery videos could facilitate training and accreditation in this complex procedure.
... According to a previous study protocol [2], anonymous laparoscopic videos were recorded and edited at Queen Alexandra Hospital (Portsmouth, UK) to demonstrate the small bowel "walkthrough" in patients undergoing laparoscopic ileocolonic resection for primary and recurrent CD during the 3-month study period from March to May 2019. The small bowel walkthrough consisted of the entire exploration of the small bowel from the Treitz ligament to the ileocaecal valve or neo-terminal ileum, using a "hand over hand" technique with atraumatic forceps [2]. ...
... According to a previous study protocol [2], anonymous laparoscopic videos were recorded and edited at Queen Alexandra Hospital (Portsmouth, UK) to demonstrate the small bowel "walkthrough" in patients undergoing laparoscopic ileocolonic resection for primary and recurrent CD during the 3-month study period from March to May 2019. The small bowel walkthrough consisted of the entire exploration of the small bowel from the Treitz ligament to the ileocaecal valve or neo-terminal ileum, using a "hand over hand" technique with atraumatic forceps [2]. All procedures were performed by a single surgeon with expertise in IBD surgery in an attempt to mitigate the confounding factors of approach variation. ...
... This lack of bowel sparing techniques reflects not only a selection bias in the videos edited for presentation to the assessors but also the difficulties in making a thorough assessment of the small bowel involvement at laparoscopy, where a trusty agreement may exists amongst surgeons on the presence of bowel thickening and mesenteric fat wrapping, but not on the evaluation of proximal lesions and severity of mesenteric disease. [2] Conclusions Our study reported high agreement amongst IBD surgeons on the main procedure to be performed in selected cases of ileocolonic CD, but the treatment of multifocal disease was highly controversial, with very 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. ...
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.
... On the contrary, some evidence exists that important proinflammatory mechanisms are unique to the mucosa and cannot be observed in the mesentery [128]. Finally, the proposed approach seems very difficult to standardized as the correct amount of the mesentery to be removed is unknown and the suggested "mesenteric disease score" to evaluate the severity 8 Journal of Immunology Research of mesenteric affection probably suffers from great interobserver variability [129]. ...
Introduction:
Postoperative recurrence after surgery for Crohn's disease (CD) is virtually inevitable, and its mechanism is poorly known.
Aim:
To review the numerous factors involved in CD postoperative recurrence (POR) pathogenesis, focusing on single immune system components as well as the immune system as a whole and highlighting the clinical significance in terms of preventive strategies and future perspectives.
Methods:
A systematic literature search on CD POR, followed by a review of the main findings.
Results:
The immune system plays a pivotal role in CD POR, with many different factors involved. Memory T-lymphocytes retained in mesenteric lymph nodes seem to represent the main driving force. New pathophysiology-based preventive strategies in the medical and surgical fields may help reduce POR rates. In particular, surgical strategies have already been developed and are currently under investigation.
Conclusions:
POR is a complex phenomenon, whose driving mechanisms are gradually being unraveled. New preventive strategies addressing these mechanisms seem promising.
