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Preoperative Magnetic Resonance Enterography in Predicting Findings and Optimizing Surgical Approach in Crohn's Disease

  • 2013 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Many Crohn's disease patients require surgery. Intraoperative detection of new lesions may lead to change in planned surgery. This study aimed to determine whether magnetic resonance enterography can optimize surgical planning and guide decision making in Crohn's disease.

Methods

Seventy-five patients with complicated Crohn's disease were enrolled and underwent preoperative magnetic resonance enterography. Analysis included imaging accuracy and change in surgical strategy due to discordance with imaging findings.

Results

Surgery was performed laparoscopically in 39/75 patients (52 %), with conversion to open surgery required in six (15 %). Concordance between observers was excellent (kappa value >0.8). Magnetic resonance enterography accuracy for stenosis, abscess, and fistula were all above 85 % in per-patient analysis. In 68/75 cases (90.7 %) surgery was correctly predicted. Conversely, in 7/75 cases (three false-positives and four false-negatives) surgical strategy (type of resection or strictureplasty, n = 5) and/or surgical approach (conversion from laparoscopy to open surgery, n = 2) changed due to discordance with magnetic resonance enterography findings.

Conclusion

Surgical strategy and approach are correctly predicted by magnetic resonance enterography in the majority of patients with complicated Crohn's disease.

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References

  1. Podolsky, D. K. (2002). "Inflammatory bowel disease." The New England journal of medicine 347(6): 417–429.

    Article  CAS  PubMed  Google Scholar 

  2. Cosnes, J., S. Cattan, et al. (2002). "Long-term evolution of disease behavior of Crohn's disease." Inflammatory bowel diseases 8(4): 244–250.

    Article  PubMed  Google Scholar 

  3. Etienney, I., Y. Bouhnik, et al. (2004). "Crohn's disease over 20 years after diagnosis in a referral population." Gastroenterologie clinique et biologique 28(12): 1233–1239.

    Article  PubMed  Google Scholar 

  4. Alabaz, O., A. J. Iroatulam, et al. (2000). "Comparison of laparoscopically assisted and conventional ileocolic resection for Crohn's disease." The European journal of surgery = Acta chirurgica 166(3): 213–217.

    CAS  PubMed  Google Scholar 

  5. Benoist, S., Y. Panis, et al. (2003). "Laparoscopic ileocecal resection in Crohn's disease: a case-matched comparison with open resection." Surgical endoscopy 17(5): 814–818.

    Article  CAS  PubMed  Google Scholar 

  6. Bernell, O., A. Lapidus, et al. (2000). "Risk factors for surgery and postoperative recurrence in Crohn's disease." Annals of surgery 231(1): 38–45.

    Article  CAS  PubMed  Google Scholar 

  7. Otterson, M. F., S. J. Lundeen, et al. (2004). "Radiographic underestimation of small bowel stricturing Crohn's disease: a comparison with surgical findings." Surgery 136(4): 854–860.

    Article  PubMed  Google Scholar 

  8. Uchikoshi, F., T. Ito, et al. (2004). "Advantages of laparoscope-assisted surgery for recurrent Crohn's disease." Surgical endoscopy 18(11): 1675–1679.

    CAS  PubMed  Google Scholar 

  9. Nolan, D. J. (1997). "The true yield of the small-intestinal barium study." Endoscopy 29(6): 447–453.

    Article  CAS  PubMed  Google Scholar 

  10. Maconi, G., G. M. Sampietro, et al. (2003). "Contrast radiology, computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohn's disease: a prospective comparative study." The American journal of gastroenterology 98(7): 1545–1555.

    Article  PubMed  Google Scholar 

  11. Parsi, M. A., B. A. Lashner, et al. (2004). "Type of fistula determines response to infliximab in patients with fistulous Crohn's disease." The American journal of gastroenterology 99(3): 445–449.

    Article  CAS  PubMed  Google Scholar 

  12. Pozza, A., M. Scarpa, et al. (2011). "Magnetic resonance enterography for Crohn's disease: what the surgeon can take home." Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 15(10): 1689–1698.

    Article  Google Scholar 

  13. Malgras, B., P. Soyer, et al. (2012). "Accuracy of imaging for predicting operative approach in Crohn's disease." The British journal of surgery 99(7): 1011–1020.

    Article  CAS  PubMed  Google Scholar 

  14. Fiorino, G., L. Peyrin-Biroulet, et al. (2013). MRE and colonoscopy findings in early Crohn's disease predict the course of the disease: a prospective observational cohort study. 8th Congress of ECCO the European Crohn's and Colitis Organisation. Vienna, Austria.

  15. Gourtsoyiannis, N. C., J. Grammatikakis, et al. (2006). "Imaging of small intestinal Crohn's disease: comparison between MR enteroclysis and conventional enteroclysis." European radiology 16(9): 1915–1925.

    Article  PubMed  Google Scholar 

  16. Florie, J., M. N. Wasser, et al. (2006). "Dynamic contrast-enhanced MRI of the bowel wall for assessment of disease activity in Crohn's disease." AJR. American journal of roentgenology 186(5): 1384–1392.

    Article  PubMed  Google Scholar 

  17. Scarpa, M., C. Ruffolo, et al. (2009). "Intestinal surgery for Crohn's disease: predictors of recovery, quality of life, and costs." Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 13(12): 2128–2135.

    Article  Google Scholar 

  18. Dunker, M. S., A. M. Stiggelbout, et al. (1998). "Cosmesis and body image after laparoscopic-assisted and open ileocolic resection for Crohn's disease." Surgical endoscopy 12(11): 1334–1340.

    Article  CAS  PubMed  Google Scholar 

  19. Maartense, S., M. S. Dunker, et al. (2006). "Laparoscopic-assisted versus open ileocolic resection for Crohn's disease: a randomized trial." Annals of surgery 243(2): 143–149; discussion 150–143.

    Article  PubMed  Google Scholar 

  20. Fiorino G, Bonifacio C, Peyrin-Biroulet L, Minuti F, Repici A, Spinelli A, Fries W, Balzarini L, Montorsi M, Malesci A, Danese S. Prospective comparison of computed tomography enterography and magnetic resonance enterography for assessment of disease activity and complications in ileocolonic Crohn's disease. Inflamm Bowel Dis. 2011 May;17(5):1073–80. doi: 10.1002/ibd.21533. Epub 2010 Nov 8.

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Acknowledgments

The authors would like to acknowledge Marie Cheeseman. This work was supported by Alcesti Scarpellini and FIRMAD (Fondazione Italiana per la Ricerca sulle Malattie dell’Apparato Digerente).

Conflict of Interest

The authors were involved in all the different phases of the study (including enrolment of patients), data analysis and writing of the manuscript. The authors did not receive honoraria for the preparation of this manuscript.

Author information

Authors and Affiliations

  1. Department of Surgery-IBD Surgery Unit, Humanitas Clinical and Research Center, via Manzoni 56, Rozzano (MI), 20089, Italy

    Antonino Spinelli, Piero Bazzi, Matteo Sacchi, Sarah De Bastiani & Marco Montorsi

  2. Department of Medical Biotechnologies and Translational Medicine, University of Milan, Rozzano (MI), Italy

    Antonino Spinelli, Alberto Malesci & Marco Montorsi

  3. Department of Gastroenterology–IBD Unit, Humanitas Clinical and Research Center, via Manzoni 56, Rozzano (MI), 20089, Italy

    Gionata Fiorino, Alberto Malesci & Silvio Danese

  4. Department of Radiology, Humanitas Clinical and Research Center, via Manzoni 56, Rozzano (MI), 20089, Italy

    Cristiana Bonifacio & Luca Balzarini

  5. Department of Hepato-Gastroenterology, University Hospital of Nancy, Vandoeuvre-le`s-Nancy, France

    Laurent Peyrin-Biroulet

Authors
  1. Antonino Spinelli
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  2. Gionata Fiorino
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  3. Piero Bazzi
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  4. Matteo Sacchi
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  5. Cristiana Bonifacio
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  6. Sarah De Bastiani
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  7. Alberto Malesci
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  8. Luca Balzarini
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  9. Laurent Peyrin-Biroulet
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  10. Marco Montorsi
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Corresponding author

Correspondence to Antonino Spinelli.

Additional information

Discussant

Dr. Guilherme M. R. Campos (Madison, WI): The paper is an important contribution as it evaluated one of the larger cohorts of patients with Crohn's, as to study accuracy of MR enterography and used a robust reference standard: surgical findings. One of the limitations of the study though, is related to the very use of surgical findings as the reference standard; as any study employing surgery as reference, will suffer from verification bias, as only highly abnormal tests resulting in reference application will be evaluated. Second is the need to better delineate the tests and algorithm used to choose open versus laparoscopic approach and also the criteria for conversion. In addition, the decision for conversion involves too many variables, and what maybe always an open procedure or a conversion in some hands, maybe a standard laparoscopic procedure in others. Lastly, the differentiation of active versus fibrotic Crohn's by MR, and validating MR findings with histological evaluation is not presented in the current analyses.

My questions are: Because MR had a few false positives, should a diagnostic lap be considered in selected patients to confirm the MR findings? And second, should MR completely replace CT enterography or are there clinical scenarios in which CT would be preferred? Thank you.

Closing Discussant

Dr. Antonino Spinelli: Thank you Dr. Campos for your comments and for your questions.

(1) Regarding the first point of the bias intrinsic in using surgery as a reference, that would be the case if our aim would have been to generally assess activity, and not complications as we actually wanted to do.

(2) I agree with you that the choice of the approach (lap or open) is very “operator dependent,” but in the present study, our aim was not to say what should be approached laparoscopically and what not, but to analyze whether MRE can help the single surgeon to correctly choose his approach for that single patient, given his own indication to lap or open surgery.

(3) Active inflammatory vs fibrotic disease remains a challenge for GE and surgeons dealing with CD and we actually have an ongoing study in which we assess inflammation and fibrosis on surgical specimen correlating them with exactly the same bowel segment at MRE.

Two brief answers at your last two questions:

(1) I do not think that a diagnostic lap (or a lap look) should be performed as a standard, because our aim is to correctly and directly address patients to the most appropriate surgical approach, but I agree that in selected cases, it can be done (e.g., in patients with doubtful MRE finding of e–e fistula).

(2) Regarding CT enterography and MRE, we published a couple of years ago prospective comparison, showing that they were able to obtain similar results and that therefore, due to the radiation exposition hazards, MRE should be preferred.

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Spinelli, A., Fiorino, G., Bazzi, P. et al. Preoperative Magnetic Resonance Enterography in Predicting Findings and Optimizing Surgical Approach in Crohn's Disease. J Gastrointest Surg 18, 83–91 (2014). https://doi.org/10.1007/s11605-013-2404-1

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  • DOI: https://doi.org/10.1007/s11605-013-2404-1

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