May's Paper of the Month looks at The SuPREMe-CD Study, a clinical trial which aimed to provide randomised controlled data comparing Kono-S anastomosis and stapled ileocolic side-to-side anastomosis.
Gaetano Luglio, Antonio Rispo, Nicola Imperatore, Mariano Cesare Giglio, Alfonso Amendola, Francesca Paola Tropeano, Roberto Peltrini, Fabiana Castiglione, Giovanni Domenico De Palma, Luigi Bucci
Ann Surg 2020;272:210–217.
What is known about the subject?
Many patients with CD require ileocolic resection but such treatment is rarely curative. Endoscopic evaluation after ileocolic resection shows that in the absence of medical treatment, the postoperative endoscopic recurrence (ER) rate is about 65% to 90% within 12 months and 80% to 100% within 3 years; at the same time, the clinical recurrence without therapy is around 20% to 25% per year. Currently, there is no consensus about the best approach to prevent postsurgical recurrence of CD with attention focused on type of anastomosis (end-to-end anastomosis vs. side-to-side); other modifiable or non-modifiable risks e.g. smoking, age-at-onset, perianal disease; and medical therapies and endoscopic monitoring to reveal early mucosal disease. Based on the fact that anastomotic recurrences arise on the mesenteric side, a new antimesenteric, functional, end-to-end, hand-sewn ileocolic anastomosis (Kono-S) was first described in Japan in 2011 with some case control data that it reduced endoscopic and surgical recurrence [1].
What the study adds?
The study randomized 79 patients with ileocolic CD to Kono-S anastomosis (n = 36) and stapled ileocolic side-to side anastomosis (n = 43). After 6 months, 22.2% in the Kono group vs. 62.8% in the Conventional group had ER [P < 0.001, odds ratio (OR) 5.91]. Severe postoperative ER (Rutgeerts score > i3) was found in 13.8% of Kono vs. 34.8% of Conventional group (P = 0.03, OR 3.32). Clinical recurrence rates were 8% in the Kono group vs. 18% in the Conventional group after 12 months (P = 0.2), and 18% vs. 30.2% after 24 months (P = 0.04, OR 3.47). Surgical recurrence rates after 24 months were 0% in the Kono group vs. 4.6% in the Conventional group (P = 0.3). Patients with Kono-S anastomosis had a longer time until CR than patients with side-to-side anastomosis (hazard ratio 0.36, P = 0.037). On binary logistic regression analysis, the Kono-S anastomosis was the only variable significantly associated with a reduced risk of ER (OR 0.19, P < 0.001). There were no differences in postoperative outcomes e.g. operative duration (there was a learning curve however), LOS and anastomotic complications.
Implications for colorectal practice
The study addresses an important issue for CR surgeons who specialise in IBD. Many reading the results will have the same initial sentiment as me “is this too good to be true?”. On critical analysis of the design and conduct of the study, there is nothing obvious to point to as a source of major systematic bias but, as the authors readily acknowledge, there are some limitations inherent in a single centre, relatively modest sized RCT. The role of the mesentery in driving recurrence based on previous studies [2] is well discussed and there is some biological rationale for the findings. I confess to having no personal experience of performing this configuration of anastomosis. Would be interesting for our members to add their personal experience on the website and I will see if our ‘comms team’ can solicit a video.
References
- Kono T, Ashida T, Ebisawa Y, et al. A new antimesenteric functional end-toend handsewn anastomosis: surgical prevention of anastomotic recurrence in Crohn’s disease. Dis Colon Rectum. 2011;54:586–592.
- Coffey CJ, Kiernan MG, Sahebally SM, et al. Inclusion of the mesentery in ileocolic resection for Crohn's disease is associated with reduced surgical recurrence. J Crohns Colitis. 2018;12:1139–1150.