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P195 Predicting surgical strategy in ileal Crohn’s disease: the construction and validation of an evidence-based, end-user informed radiological staging tool

P. Morar*1, E. Mainta2, S. Arora3, R. Ilangovan2, A. Hart1, A. Gupta4, J. Warusavitarne1, O. Faiz1

1St Mark’s Hospital, Colorectal Surgery & IBD Unit, London, United Kingdom, 2St Mark’s Hospital, London, United Kingdom, 3Imperial, London, United Kingdom, 4St Mark’s Hospital, London, United Kingdom

Background

Consensus guidelines recognise the importance of multidisciplinary team driven care for patients with ileal Crohn’s disease.1 There are, however, no clear definitions of ileal Crohn’s beyond the presence or absence of pre-operative intra-abdominal sepsis.2,3 This study aims to provide stages for ileal Crohn’s disease based upon best evidence and end-user expert opinion. The secondary aim is to validate these stages.

Methods

Items for the staging tool were developed using a literature review and semi-structured interviews. Validation was performed using magnetic resonance enterography (MRE), which was used to provide a pre-operative stage for patients who have undergone ileocolonic resection. Outcome variables included complication rates, operative strategy, and stoma rates. A univariate analysis was performed using multinomial regression analysis. Significance was determined with a p-value < 0.05.

Results

A 4-stage system was constructed from items through literature review and semi-structured interviews of IBD experts: stage 1, predominantly inflammatory ileal stricture; stage 2, predominantly fibrotic ileal stricture; stage 3, fistulating disease (including entero-vesicle/entero-vaginal/entero-cutaneous/multiple fistulae); and stage 4, intraabdominal abscess or collection. Further, 69 patients had MRE before surgery. Stages 1, 2, 3, and 4 disease were present in 35 [50.7%], 5 [7.4%], 21 [30.9%], and 8 [11.8%], respectively. In comparison to those with stage-1 disease, there was a higher proportion of stoma formations in patients with stage-4 disease (4/34 [12%] and 5/7 [63%]; p = 0.003), and a higher proportion of patients having concomitant bowel surgery with stage-2 (5/35 [15%] and 4/5 [80%]; p = 0.01) and stage- 3 (9/21 [43%]; p = 0.03) disease.

Table 1 Demonstrating evidence-based, end-user informed 4-stage system, alongside peri-operative outcomes for N = 69 cases of ileal Crohn’s whose preoperative MRE were staged

Conclusion

Standardisation in the management ileal Crohn’s disease is required to reduce the variation of treatment strategies and improve the quality of care patients receive. This staging system has demonstrated a higher proportion of patients undergoing concomitant bowel resection and/or strictureplasty with stage-2 and stage-3 diseases, when compared with patients with stage-1 disease. It has also demonstrated a higher proportion of stoma formations in patients with stage-4 disease. Further multicentre prospective validation is required.

References

[1] IBD Standards Working Group. Quality care: service standards for the healthcare of people who have inflammatory dowel disease. IBD Standards Working Group; 2009.

[2] Morar P, Read J, Arora S, et al. Defining the optimal design of the inflammatory bowel disease multidisciplinary team: results from a multicentre qualitative expert-based study. Frontline Gastroenterol 2015; DOI: 10.1136/flgastro-2014–100549.

[3] Hulten L. Surgical treatment of Crohn’s disease of the small bowel or ileocecum. World J Surg 1988;12(2):180–85.