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We commend Spinelli and colleagues on their study on preoperative MRI enterography for presurgical planning in patients with Crohn’s disease.1 The independent blind reporting provides strength to the study. We have several points for the author’s consideration.
Firstly, did the authors consider the use of magnetic resonance enteroclysis? Another study of preoperative MRI interpretation achieved 100 % sensitivity and 100 % specificity using MR enteroclysis (MRE) with nasojejunal administration of polyetylenglycol solution.2 This can significantly improve preoperative diagnostic accuracy of preoperative planning.
Second, the specificity and sensitivity of any study are dependent on the incidence of complex pathology. Your series predominantly comprises of small bowel and ileocolic stenosis. Therefore, we would recommend further validation with a more complex disease case mix. In addition to test the generalizability of this study, we suggest validation with generalist as well as specialist IBD radiologists and possibly external validation of the cases and images at another centre. Was there any correlation between scans with radiologist disagreement and change in the operative approach? If so, this could highlight cases which possibly require further imaging, possibly by MRE.
Third, there was excellent agreement in the identification of stenosis and fistula (k > 0.80), but less so for the detection of abscesses (k = 0.61–0.80). This is clinically important as patients with intra-peritoneal abscesses identified on MR were operated directly by the open approach. One can convert from laparoscopic to open, but not vice versa. Was there any data to suggest that cases of false positive MRI findings could have been approached laparoscopically in retrospect? In recent years, we have favoured a laparoscopic first approach in our institution in the hands of experienced laparoscopic IBD surgeons.
We thank the authors again for their contribution to the important issue of preoperative imaging to assist surgical planning in patients with Crohn’s disease.
References
Spinelli A, Fiorino G, Bazzi P, Sacchi M, Bonifacio C, De Bastiani S, et al. Preoperative magnetic resonance enterography in predicting findings and optimizing surgical approach in Crohn’s disease. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract. 2014 Jan;18(1):83–91.
Negaard A, Paulsen V, Sandvik L, Berstad AE, Borthne A, Try K, et al. A prospective randomized comparison between two MRI studies of the small bowel in Crohn’s disease, the oral contrast method and MR enteroclysis. European Radiology. 2007;17(9):2294–301.
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Morar, P., Bagnall, N.M. & Faiz, O. Letter of Response to Article: Preoperative Magnetic Resonance Enterography in Predicting Findings and Optimizing Surgical Approach in Crohn’s Disease. J Gastrointest Surg 18, 1721 (2014). https://doi.org/10.1007/s11605-014-2535-z
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DOI: https://doi.org/10.1007/s11605-014-2535-z