Handsewn anastomosis after ileo-colic resection for Crohn's disease: a lost art?

Ileo-colic resection (ICR) is the most common surgical procedure for Crohn’s disease (CD). Reconstruction is most commonly achieved with stapled side-to-side (SSTS) or hand-sewn (HS) ileo-colic anastomosis (ICA). We aimed to compare short-term complications and long-term recurrence-free survival (RFS) of CD between patients who underwent SSTS vs. HS anastomoses in our institution. This study was a retrospective analysis. Patients who underwent ICR and ICA for terminal ileal CD from January 2012 to December 2016 were included. Surgeries were done for 26 surgeons. Patients with stoma or other types of anastomoses were excluded. The groups were compared in a univariate analysis. Recurrence (Rutgeerts ≥i2 or active disease on CT/MRI) was assessed using Kaplan–Meier curves and a log-rank test. Cox-proportional hazard and linear regression models with propensity score inverse probability of treatment weighting were used to further evaluate postoperative outcomes and recurrence of CD. Numbers represent median or proportion as noted. Were included 59 patients in HS group and 202 in SSTS group. HS group had a longer course of disease (16 vs. 9 years, p = 0.005), were more likely to have previous surgeries (59 vs. 42%, p = 0.02), perianal disease (39 vs. 23%, p = 0.02) and redo ICA (56 vs. 33%, p = 0.001). There was no difference in use of medications. More HS patients were ASA 3 (65 vs. 40%, p = 0.004), and HS operations were longer (157 vs. 133 min., p < 0.001), with more blood loss (150 vs. 50 ml, p < 0.001), and fewer laparoscopies (41 vs. 65%, p < 0.001). Patients who underwent HS had more experienced surgeons (16 vs. 11 years, p < 0.001). HS patients had longer lengths of stay (6 vs. 5 days, p = 0.02) Figure 1. Univariate analysis of perioperative variables and short-term outcomes within 30 days. Outcomes within 30 days. There was no difference in recurrence rates Figure 2. Kaplan–Meier plot for recurrence-free survival and log rank test. RFS curve. After propensity score weighting and adjustment for covariates, HS patients had less than 1/3 of the odds of Clavien-Dindo ≥3 complication compared with SSTS group (OR 0.29 [0.09–0.92], p = 0.03). HS anastomoses, compared with SSTS anastomoses, were independently associated with a lower rate of major postoperative complications, despite being performed in more complex patients. In addition, no difference in recurrence rates between groups was observed. Thus, colorectal surgeons should be facile and confident in performing HS procedures, especially in difficult situations, lest HS become a lost art.