Timing of ileocolonic anastomosis in ileocecal resection in Crohn's disease

ABSTRACT Background - Crohn's disease (CD) is a chronic inflammatory disorder affecting the gastrointestinal tract with no current curative treatment. Despite significant improvements in medical treatments, surgery is still necessary in most cases, especially in the management of complications. Intestinal resection of the terminal ileum followed by ileocolonic anastomosis is the most performed surgery for Crohn's disease since it typically affects the terminal ileum. Among different types of anastomoses, the side-to-side anastomosis is currently recommended by European Crohn’s and Colitis Organisation (ECCO) guidelines, and the laparoscopic method appears to be preferred. However, it remains uncertain whether performing the anastomosis intracorporeally or extracorporeally ultimately affects postoperative outcomes, leaving the decision up to the surgeon. Currently, there are no studies in the literature comparing these outcomes in ileocolic anastomoses. Therefore, our study aims to investigate any differences between the two anastomosis types in terms of disease activity, body image, quality of life, operating time, and clinical and surgical recurrence-free survival time. Methods - We performed a retrospective analysis of 50 consecutive patients who underwent ileocecal resection followed by ileocolonic side-to-side anastomosis in our department from 2020 to 2023. For each patient, surgical records, discharge letters, and outpatient follow-up visits were thoroughly analyzed. In July 2023, 48 patients agreed to participate in a telephone interview to assess patients' clinical disease activity (Harvey-Bradshaw), quality of life (Cleveland Global Quality of Life), and body image (Body Image Questionnaire) after surgery. Results – 16 and 34 patients underwent intracorporeal and extracorporeal anastomosis, respectively. The disease activity (Harvey-Bradshaw Index) did not show significant differences in single item or total HBI scores between the two groups. However, patients with extracorporeal anastomosis had slightly higher scores for item HB3 (number of liquid/soft stools per day) (p = 0.0778), moreover patients with extracorporeal anastomosis had a slightly higher HB total score (p = 0.0580). The Body Image Questionnaire (BIQ) results indicated that patients who underwent intracorporeal anastomosis were more satisfied with their bodies (BIQ1, p = 0.0270), felt more attractive (BIQ3, p = 0.0570), and felt more masculine/feminine (BIQ4, p = 0.0814) compared to those with extracorporeal anastomosis although only the first item showed a statistical significance. We performed additional analysis of the results, specifically excluding patients who underwent open surgery. The previously slight differences were no longer observed, except for item BIQ1 (p = 0,0257). No differences were found in quality of life, health, energy level, or postoperative complications between the two groups. However, in terms of operating time, intracorporeal anastomoses showed a slightly shorter operating time, although this did not reach statistical significance. On the other hand, intracorporeal anastomoses appear to be associated with a slight, though not statistically significant, tendency to recur. Conclusions - Our study suggests that intracorporeal anastomosis seems to have slightly functional and aesthetic advantages compared to extracorporeal anastomosis, although these findings did not reach statistical significance. In addition, intracorporeal anastomosis appears to be faster to perform, but it seems to be associated with a higher likelihood of disease recurrence. In terms of postoperative quality of life, no significant differences were observed between the two types of anastomoses, and there were no significant differences in postoperative complications. It's important to note that these results are based on a limited sample size and follow-up period, and further studies are needed for confirmation.