BTK Episode 3 - Journal Review CCF CORS
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[00:00:00] Hi everyone and welcome to Behind the Knife. I'm Alyssa Deba, a general surgery resident at Cleveland Clinic.

And I'm Jared Hendron, another general surgery resident at Cleveland Clinic. And we're joined by members of our colorectal surgery team.

Hi there. I'm Dave Rosen, the vice chair of the Department of Colon colorectal surgery, and the section head of the division of colorectal surgery at Cleveland Clinic Fairview Hospital.

And I am AJ Shinra, one of the assistant professor in the Department of Colorectal Surgery. To fe.

And I'm Joseph Rezo. I'm the, uh, program director for the General Surgery Residency Program.

Alright. And

also

a colorectal surgeon. We'll, we'll keep you as part of our team.

And I'm a colorectal surgeon.

Yeah. Congrats to Dr. Rezo. He was just named the general surgery program director for us.

Yep.

And we're very excited. Um, so let's go ahead and get into our discussion. It's well known that a significant portion of patients with Crohn's disease will require surgery. Typically an ileocolic resection, and while surgery can be highly effective for symptom control, [00:01:00] recurrence is the rule rather than the exception.

And depending on the definition, endoscopic recurrence can occur in 50 to 60% of patients within one year, and clinical recurrence can occur in up to 40 to 50% of patients within five years. In an effort to reduce recurrence, surgeons have focused on the configuration of the anastomosis, the development of novel anesto techniques, and the role of the mesentery itself.

Today we're going to discuss three journal articles that reflect this evolution in thinking and discuss how they help shape the way we approach ileocolic, resections, and anastomosis and Crohn's disease. So our first paper focuses on the question, does anastomosis type matter at all? A while ago, McLeod ET al, published a multicenter RCT in the diseases of the colon and rectum in 2009, assessing endoscopic and symptomatic recurrence at 12 months for patients who had a stapled side to side anastomosis versus a hand zone.

[00:02:00] End-to-end anastomosis 139. Total Crohn's patients were included in the efficacy analysis. 66 had a side to side, and 73 had end-to-end anastomosis. And their studies showed that endoscopic recurrence at 12 months was similar between groups with 37.9% of side to side anastomosis patients, versus 42.5% of end-to-end anastomosis patients experience recurrence.

Similarly, there was no STA statistically significant difference in indifference in symptomatic recurrence with 22.7% of side to side anastomosis patients versus 21.9%. Um, end-to-end anastomosis patients experiencing symptomatic recurrence.

Great. Okay, so let's talk about how these results could apply to a patient in clinic.

So you have a symptomatic 28-year-old man with ileocolic Crohn's disease. Um, he has fibro stenotic disease and a short stricture. And he hasn't trialed any [00:03:00] biologics yet. He's otherwise healthy non-smoker, and he's undergoing IOC Clic resection with you. So prior to the kno s anastomosis, what anastomotic technique would y'all perform for this patient?

And would this be patient specific? And also what is y'all's thoughts in general deciding on anastomosis you'll be creating for a patient with Crohn's?

So, so I think that to sort of set the stage is important to point out. We're talking about this because this is such a problem. The disease and the biology of Crohn's disease is such a problem, and we're trying to figure out how do we help patients.

Get their surgical resection and not have to have another one because the more you keep taking and taking and taking, you will end up with short gut and have other complications. So I think it's important to point out that we don't know exactly what the best way to prevent that from happening is.

So we're, we're investigating and experimenting with new techniques. And so that I think is important to set the stage before we each kind of go around and talk about what is our personal preference, uh, and, and [00:04:00] why.

So I'll say. Just like with a lot of things in surgery, they're having more technique in your toolbox is probably gonna be beneficial when you're managing a disorder like Crohn's Disease.

And then early in my career, it was very common that we would just simply do a side to side anastomosis. Because it's a wider connect. You can make a nice wide anastomosis as long as the small bowel and the colon were, um, soft and healthy. I've evolved from that and a lot of people have, I'm talking about stapled anastomosis to an endo side for a couple of reasons.

One with an endo side anastomosis, it's a little more simplistic to intubate the, the terminal ileum after an endo side. Ileal colic anastomosis from a gastroenterologist and sort of surveillance standpoint, and also invariably if they develop a stricture at that anastomosis. It's also a little more simplistic to dilate a, a steno stricture at a circular anastomosis opposed to sort of an oblong angle from a end, a [00:05:00] side-to-side function end, end to end anastomosis.

So, my routine on an elective ilio colic resection with otherwise healthy bowel would be an end side. And that's my current preference.

And tell us real quick, how do you do that specifically when you're talking about end?

So typically, we, I will use a, a circular end-to-end stapler, EEA stapler the, an will sewn into the small bowel through the proximal or the proximal of the colon, typically around the cecum.

We will insert that, that stapler and bring the, uh, pin out the anti mesenteric border of the ascending of the proximal ascending colon. And once that's done, you create your end to side ileal colic anastomosis with your circular stapler. And then. Yeah, there's a various ways you can deal with the, the cecum be whether you resect it and primarily close the stump, or you use a TA staple to fire across the, um, the ectomy portion of your colon.

Yeah. For me, I'm, I'm definitely, I'm definitely of reflection [00:06:00] of my training. So in residency we tend to do end to side and then fellowship. We did a lot of side to side. So you know what I'm most comfortable with for a lot of the reasons Dr. Trusler just mentioned is doing an ide. So I tend to use a 28 EA purple stapler.

To do my genocide and most patients, um, honestly, I can't really think of any reason I'm not able to do that, and then I'll switch those side-to-side. I tend to do genocide nowadays. Just I'm more comfortable with that now.

Yep. I will add one other c component to this. If the patient has been chronically obstructed at the site of the IOC colic disease and they have, they'll have emus, sort of proximal small bowel that is healthy and not part of their disease process.

Sometimes I would try to refrain from a staple. I worry about a staple anastomosis when the bowels very emus. Um, and in that situation I would do a hand zone. And kind of going back to this, this study that you were talking about, an end-to-end anastomosis, typically what I would do is actually do an isop peristaltic side to side which endoscopically.

Fairly [00:07:00] easy to get yourself navigated from the colon into the small bowel with an isop peristaltic anastomosis. And I can also create the width I'm looking for when I do it side to side as, as opposed to end to end. You're sort of beholden to the end of the, the bowel.

Yeah, I think those are all great points and I, I, my practice is, is pretty similar.

The only thing I'll really add is that I think there's a lot of times, and, and Joe, you started to get into it just there, patient factors matter a lot with what you find intraoperative. Um, and I really try myself to avoid diverting loop ileostomies in Crohn's patients when possible for IOC colic resections.

So for me, I'm either doing an anastomosis or an end ileostomy and letting things settle down and then come back another day for the anastomosis. Depending on the patient factors, how much creeping factor is, right? Because if it's, if you only have a sliver of an anti mesenteric end, sometimes sewing in that anvil for endemic is not easy.

You're kind of coming through and then you try to clean up some of the fat and it starts bleeding and shredding. So that might be a time that I would think about an isop peristaltic side to side where you fire a linear stapler in an isop peristaltic fashion and then hand [00:08:00] sew close that, that gap.

But I would say my, my, my standard is uh, either an end side exactly the way Dr. Rezo, uh, described ilio colic anastomosis, or the cones, which we'll talk about uh here shortly. But there's, there's patient factors. Uh, and I used to think, like Dr. Choler mentioned that having a wide open anastomosis, when I first started, I was doing a lot of anti peristaltic, peristaltic, siic sides, and we always thought that wide anastomosis maybe would help.

But when you think about it, when the patient recurs, it's usually just proximately anastomosis where that kind of stricter and narrowing happens. So I think the width of the actual anastomosis itself might matter a little less than we used. You used to think. And so typically I'll, I'll do a, an end decide with a 31.

Uh, EEA, uh, anvil, uh, and, and versus a, a large cs. Uh, and that's kind of my, my standard.

Yeah. Great discussion guys. So, um, recently, uh, meta-analysis by IGN at all that was published in an international Journal of colorectal disease also showed no significant [00:09:00] difference in endoscopic recurrence between stapled side to side and hand zone.

End-to-end anastomosis. But as mentioned that, that you guys talked about, there are many other things to consider when you're choosing the type of anastomosis for Crohn's patients. And, uh, while we won't get into the details of the study, I do think it is interesting that Con os anastomosis showed a trend toward lower endoscopic recurrence in that group compared to the side to side group at 31.8% versus 39.8% respectively.

Um, when considering endoscopic follow up between six to six to 12 months. Um, but this conclusion in their, their study was limited due to variation in study design definitions and postoperative management. But this does set up, uh, set us up well for our next paper.

Great. So yeah, our second paper focuses on, you know, this novel Anastomotic Techniques and it's the Supreme CD trial published in analysis of surgery in 2020.

Um, this was the first RCT comparing the KOS [00:10:00] anastomosis to a conventional stapled side to side anastomosis in Crohn's disease patients, um, that were undergoing IA colic resection. So the kno s is an anti mesenteric functional end-to-end hand, so anastomosis that places the anastomosis away from the disease mesentery and reinforces it with a central supporting column.

The primary endpoint was endoscopic recurrence defined as root geared score of I two or higher at six months. 79 patients were randomized 36 to the KNO S group and 43 to the conventional group. Um, at six months, endoscopic recurrence occurred in 22% of the KNO S group compared to 63% of the conventional group.

At 24 months, clinical recurrence was 18% versus 30%, and surgical, surgical recurrence was 0% versus 4.6%. Um, so there was no difference. Um, and post-op complications between the two groups as well.

Yeah. Now let's talk about how these results could apply to a patient scenario. [00:11:00] We have a 38-year-old woman with a, let's say, five year history of IOC colic, Crohn's disease fibrous stenotic failed two biologic now, now presenting for elective ioc colic resection, no prior abdominal surgery.

Preoperative imaging shows isolated terminal ileal disease with a short s stricture and. She's asking you whether the, the type of anastomosis matters for her risk of recurrence based on the Supreme CD trial. How would you counsel her and has this trial changed how you, um, has it changed your practice essentially?

I'll ask that.

So, I, I'll personally I'll say is, and these patients um, sometimes are, are like this. They're very, very into what's going on. She actually is asking about what type of anastomosis. Uh, would matter. And, but that does sometimes happen. And so, you know, I, I think that this trial and the cones, anastomosis was very exciting, I think for surgeons because so much is moving away to patients not [00:12:00] needing us, right?

All these biologics, they don't need us anymore as much for Crohn's disease. Rectal cancer management is going towards watch and wait. So here is something that we as surgeons can help contribute with the way we're constructing. Are anastomosis in these, in these uh, Crohn's patients. So I think it's very, very ex exciting.

You know, there, there is really good data. All, most, pretty much all the data for the most part is European. And, you know, this data shows that the, you know, that 22 versus 63% uh, decrease in endoscopic recurrences quite, uh, impressive. The, the problem. And, and, you know, with a lot of these European trials, the, the knock on them that people talk about is.

Pre and even, and especially postoperatively, the rate of biologic treatment of these patients was quite low. You know, half or even less than half of the patients were on biologics. And so there's a, uh, uh, trials going on in the US now that'll look at that and have aim to have a higher rate of postoperative biologic treatment.

To help answer the question, is it truly the anastomosis [00:13:00] itself or if they were on biologic treatment, would that negate any benefits made from the anastomosis? This, I will say that, you know, the, the rationale of it makes sense, right? You know, we've sort of shifted towards thinking that the mesentery is, is a, a large component of this disease process.

And so you're getting the anastomosis away from the mesentery. Most of these, uh, uh, trials or most of the people, the way that people do this, involves a mesenteric uh, extended mesenteric excision, which we'll talk about in the next paper as well. And so, dealing with the mesentery, right, focusing on how we do the.

And dealing with the mesentery, I think really adds benefit and, and makes sense now. Well, will it play out that biologics are supreme and, and it might not matter if they were patients on postoperative biologics that, uh, uh, remains to be seen, but there's no doubt that the con os uh, has been shown to be beneficial in a patient like this.

I think, you know, one of the things is, talk about the technical considerations in it. Obviously it's. It's a more demanding technical proportion. So the surgeon himself has to have a better understanding of [00:14:00] how to do the, yeah, do the, um, anastomosis in this way. We've all been pretty well taught on how to do hands on anastomosis and staple anastomosis, but this, the setup from this three to in three dimensions and how you kind of think about it, I think you take some time to kind of understand how you're gonna do it.

Um, so when you're starting to bring this in as part of your practice. You just have to make sure that you have a good understanding of what you're trying to accomplish at the time of the operation. I mean, Dr. Rosen, when you started doing these more often, like what were some of those technical limitations that you ran into or things that you're just like, I had to do to kind of set yourself up for success with it?

Yeah, just like any, uh, new uh, technique that you adopt that you haven't necessarily done in your training you're uncomfortable with. There's, there's a lot of getting used to it and, and, and, you know, part of it, it starts with. Observing people do it, whether it's watching on videos or having partners that you know, do, that you can go and observe and watch and at, you know, you have to, you can practice suturing, you know, if you have access to, you know, some, you [00:15:00] can, you can go out and buy some pig intestine or something, you know, at the local market and sort of put things together.

No, I'll, I'll be honest, I didn't do that, but it's an option. And, um, but you, and then at some point you have to kind of know, it's, I think we all have, as surgeons all have to, uh, you know, push ourselves to the next limit and do what's best for our patients. That was it. And at some point you kind of have to have to dive on in.

There's, there's no doubt that one of the big downsides of it is it takes longer. I'd say it adds about an hour to my, uh, to my operation doing it this way. It's a lot of suturing. You know, there's new techniques coming out that aren't, haven't been studied like this in terms of how to do it in a stapled fashion, which I think would appeal to people a little bit more in terms of saving on some of that time.

Um, but whether those have the same benefits, uh, as the, the suture COAs anastomosis. Remains to be seen. It needs to be needs to be studied, but there's no doubt it adds time. There's no doubt. Just like any uh, new, uh, technique, you start off and you're gonna be uncertain. Like, oh, is that the right?

Especially as you're turning corners as you come around on some of these aspects, [00:16:00] is that the right amount of turn? Am I doing this the right way? Should I canal this stitch? Should I not? And, and those are the types of things. I think whenever you adopt something new, you have to, but you have to rely on your basic foundational knowledge of HandsOn and anastomosis and your training.

And, uh, keep powering through to do new techniques to, uh, be better for our patients.

Yeah, I mean, I think at this, um, point in time, based on the current data, I will still be doing ides. Um, I would like to see a add toed comparison of IDE versus corno s to really make sure that there is a clinical significance.

'cause I do think that, you know, endoscopic recurrence is one, but the, what is the significance of that? Are these patients requiring to be on biologics? Are they requiring surgery? So I would like to see some kind of. Substantial data regarding that for me to make a switch in my practice. Um, and some of it's just based on my comfort level.

Um, I was not trained to do Cornell as a more, more reflective of that on that than anything. So.

Okay. Our third discussion combines two papers that together ask a different question. [00:17:00] Does what we do with the Mesentary during resection affect recurrence? The first of these two papers is the Meso Colic trial.

Published in early 2025, it was an international multicenter RCT that randomized 116 patients undergoing primary IOC colic resection to either extensive mesenteric excision, um, which was defined as resection up to one centimeter from the root of the ileocolic artery and vein, or conventional limited mesenteric excision where the mesentery was preserved within three centimeters of the bowel wall.

The primary endpoint was surgical recurrence with endoscopic recurrence as a secondary endpoint. And, um, I think it's important to read this alongside the SPICY trial, um, which was published in the Lancet, gastroenterology and Hepatology in 2024 which was the first RCT on this question. The spicy trial enrolled 139 [00:18:00] patients and found that extended mesenteric, resection was not superior to conventional resection for endoscopic recurrence. And there was also a signal toward higher anto leak rates, um, at 8% in the extended resection group versus 2% in the mesenteric sparing group. Um, the meso colic trials interim analysis did suggest a benefit for an extended excision on endoscopic recurrence, but the, uh, COVID-19 pandemic led to.

Missing endoscopic follow-up data in more than 20% of patients, which of course significantly complicates the interpretation of those results. And a key technical difference between the trials is the spicy trial preserved the ileocolic vessels while the meoc colic trial did not. And that distinction also, um, and how extended is defined may matter.

Um, biologic.

Right. So here's our next case. We have a 45-year-old man with [00:19:00] IOC colic, Crohn's disease. He's presenting, uh, with his first resection after failing infliximab and another anti TNF medication. Um, he's a non-smoker. No previous surgeries. His pre-op CT showed marked, uh, mesenteric thickening and his gi uh, plans to restart a biologic post-op.

But given the meso, colic and spicy trials, would y'all perform an extended mesenteric excision in this patient? Um, does this significant mesenteric thickening on imaging change your decision? And kind of more broadly, are we moving toward, um, oncologic type resections for Crohn's? And what are the risks with, with all of those things?

So, my feeling on this is, you know, we, there, there are some surgical principles you have to keep intact. Obviously one of the things about the integrity of your anastomosis is profusion and, you know, what are we sacrificing to keep pushing the envelope on what we don't know for sure is really you know, sort of a stimulus for our [00:20:00] reactivation of Crohn's is this thickened mesentary and having residual mesentary there gonna be what's gonna do it.

But I, but I will tell you the morbidity of having an anastomotic leak in this situation is real. Doing a high ligation, sort of a mes uh, mesentary high me. Ex excision in this area. And then preservation of the colon perfusion is also something to take into consideration. 'cause you, when you, when you start taking IOC colic high, an ileal ectomy is not exactly you know, a safe operation because the ascent and colon is still requiring profusion from the middle colic vessels.

So you do have to be cognizant and you end up having to take more colon as a result of a high IOC colic resection. Um, for this anastomosis right now, based on the data that we have, I don't know that I would chase extra mesentery at the, at the sort of the consequence of increasing my anastomotic leak rate.

I'm not sure that that's the right approach yet until I see more information to suggest [00:21:00] otherwise.

Yeah, I mean, I agree with Dr. Zo. I mean, I do think there's something to be said for the mesenteric disease that we see in Crohn's, um, when you're trying to come across those mesenteric with an energy device.

It's sometimes just impossible. So, and you know, you can see when you physically looking at the bowel, you know that, how this can be contributing to the pathology. But you know, short of taking out the disease bowel that's associated with the mesentery I mean the mesentery that's associated with the disease bowel, um, I certainly don't go chasing after the mesentery to do an extended at this point in time without more data.

So, um, I definitely agree with.

For the trainees that are listening to this podcast, you know, when you're dealing with that thickened ileal mesentery or Crohn's related mesentary, using an energy device to take the mesentary is really a, a, a, not a acceptable means to deal with it. These are things where you actually do have to, whether you're suture ligating or tying off, these are, you actually have to control that mesentery much better.

And those seal [00:22:00] devices, those bipolar energy devices are not equipped to handle this, these thickened mesentary to actually seal those vessels appropriately. And you will have postoperative bleeding. It's invariably will happen.

Yeah,

I agree. Yeah, I think, you know, I, I agree that this kinda goes back to my point in the, in the beginning, that a lot, I adjust a lot of my management based on intraoperative patient specific factors.

So I do think the mesentary, I, I do believe that that has something to do with this disease process. So if I'm able to get it out, I do try to get it as much as I can. That being said, uh, if. We've all encountered the Crohn's spaces where the whole thing is, the whole mesentery is like a sheet of concrete and it's super thick.

And if you go trying to take that right next to the to take the IOC right next to the SMA, you, you could potentially be in the world of her. 'cause if that's bleeding, you're trying to control it, and then you get in the SMA that it would be a miserable, really devastating complication. So in that case, I think it's, you know, that's more of a.

A biologic disease process issue, and you're [00:23:00] not gonna fix the rest of the underrated mesentery throughout that patient by taking just the, a little bit more of the part you're resecting. So yes, I will try to get do an extended mesentary excision in terms of, get as much out of it as possible.

But I, I'm very cognizant and wary of central thickening of the mesentry to taking it too high, because when that invariably bleeds even after. Tying off suture ligating, it still will start bleeding through. Then you're starting, you're trying to throw stitches and figure out, how do I get this to stop?

You don't want to be close to the SMA having that or the SMV having that problem. So, so to summarize, I'll try, but it, it, I'm not, you know, losing sleep if I'm unable to based on the patient's intraoperative factors.

Yeah, and to piggyback really quickly of what Dr. Rosen saying, even when you clamp, clamp and, you know, cut and suture leg, get those thickened mesentary that sometimes can get a hematoma.

So now imagine you have this hematoma that's expanding so close to like SMA. So, just something else to bear in mind. Like I have, I've seen a couple of [00:24:00] expanded hematomas in this situations that makes me very uncomfortable.

Good point. Yeah. Great discussion guys. Uh, we only have a few more minutes left.

So to bring it all together, um, you know, we discuss, does the anastomosis type even matter? We talked about a more novel anastomosis. And if that is more beneficial. Um, the Conno s anastomosis. And then we also talked about is it less the anastomosis and more the mesentary? Should we be doing, um, an extended mesenteric excision, um, or not?

And you guys all brought up some great points. And so how would you each summarize your current approach to, uh, ileocolic resection and anastomosis in your Crohn's?

Yeah. So I mean, I think, um, the mesentery is definitely contributing to the disease, so I do try to resect what's safe to resect in, uh, when I'm doing my IOC colic resection.

My, at this point in time, I'm still, like I said before, I'm gonna continue to do IDE until I see more data from Cornal s and once I do, I'll make sure to get some. Pig intestines [00:25:00] so I can learn how to do corn west properly or just go watch that and do it.

I'll, I'll send you a discount code for a local grocery store.

Sounds good. But yeah, that's, you know, so that's my thought regarding the case.

I would, I would summarize my uh, uh, thoughts. As for the anastomosis, I wanna make it easy for my GI colleagues to be able to scope and monitor the ti. So I'm doing either a cones, anastomosis, or an end decid anastomosis as my two preference, uh, points.

I'm trying to get out the mesentery as much as I can because I do think that contributes, uh, uh, to the um, uh, disease process. But I think it's important to be versatile and adjust based on intraoperative factors. And again, I try to do either an end ileostomy or a net or ileocolic osmosis and avoid diverting loop ileostomies when possible.

Mm-hmm.

And uh, my final thoughts are, you know, again, my go-to. Sort of anastomotic construction is gonna be an ide if I'm using a staple. If I think the tissue quality cannot, is not [00:26:00] equipped for a stapled anastomosis, it's too thickened approximately from chronic obstruction and whatnot, an edema in the bowel if I am gonna do anastomosis as opposed to bringing up an end.

As Dr. Rosen mentioned, I have a similar sort of thought process on, um, I would do a hands on iso peristaltic anastomosis. Side to side, ISOP Peral. That's sort of my preference. And as far as handling the mesentary, I do plan, I do take extra mesentary, but I would not climb up the, uh, pedicles. Um, at least I'm not ready for that jump until I see a reason to start doing that, to, at least at this stage of the game.

And, um, but that's probably my final thoughts on the, on my I call resections. Um, I believe that's gonna end our discussion today. Thanks everyone for tuning in and dominate the day.