P204 The predictive value of ileocaecal resection margins for postoperative Crohn’s recurrence
K. Wasmann*1, J. van Amesfoort2, M. van Montfoort3, L. Koens3, W. Bemelman2, C. Buskens2
1Amsterdam UMC, Department of Surgery and Gastroenterology, Amsterdam, The Netherlands, 2Amsterdam UMC, Department of Surgery, Amsterdam, The Netherlands, 3Amsterdam UMC, Department of Pathology, Amsterdam, The Netherlands
Surgical guidelines on Crohn’s disease (CD) recommend limited resection for terminal ileitis, resecting only macroscopically affected bowel. However, recent studies suggest microscopic inflammation at resection margins as a predictive factor for postoperative recurrence. The clinical impact remains unclear, as non-uniform pathological criteria have been used. The aim of this study was to assess the predictive value of pathological characteristics at ileocolic resection margins for CD recurrence.
Both resection margins of 106 consecutive patients undergoing primary ileocaecal resection for CD between 2002 and 2009 were scored for active inflammation according to the validated Geboes score, myenteric plexitis, and granulomas. Pathological findings were correlated to recurrence, defined as recurrent disease activity demonstrated by endoscopy (Rutgeerts score ≥ i2) or imaging (preferably MRE (MaRIA score ≥ 7), requiring upscaling medical treatment.
At the proximal (ileum) and distal (colon) resection margin active inflammation was found in 27% and 15% of patients, myenteric plexitis in 37% and 32%, and granulomas in 4% and 6% of patients. In total, 47 out of 106 patients developed recurrence. Only active inflammation at the distal resection margin was an independent significant predictor for recurrence (recurrence rate: 43% vs. 88% vs. 51% for active inflammation at proximal, at distal and non-involved resection margins, respectively,
Active inflammation at the distal colonic resection margin after ileocaecal resection identifies a patient group at high risk for postoperative recurrence. In contrast, inflammation at the proximal ileum resection margin did not have any prognostic significance, confirming that more extensive resection is not likely to reduce recurrences. Moreover, these results suggest that patients with active inflammation at the distal colonic resection margin represent a different prognostic phenotype of CD (ileocolonic L3 disease instead of terminal ileitis L1 disease only), in which prophylactic medical therapy should be considered. Therefore, pathological evaluation of the resection specimen should be implemented in daily practice.