SURGICAL MANAGEMENT OF ADULT CROHN’S DISEASE AND ULCERATIVE COLITIS PATIENTS: A CONSENSUS FROM THE BRAZILIAN ORGANIZATION OF CROHN’S DISEASE AND COLITIS (GEDIIB)

ZABOT, Gilmara Pandolfo; CASSOL, Ornella Sari; QUARESMA, Abel Botelho; GONÇALVES FILHO, Francisco de Assis; BAIMA, Júlio Pinheiro; IMBRIZI, Marcello; ROLIM, Alexandre de Sá; CARMO, Alexandre Medeiros do; ALVES JUNIOR, Antonio Jose Tiburcio; SANTOS, Carlos Henrique Marques dos; SOBRADO JUNIOR, Carlos Walter; MIRANDA, Eron Fábio; ALBUQUERQUE, Idblan Carvalho de; SOUZA, Mardem Machado de; KAISER JUNIOR, Roberto Luiz; PARRA, Rogerio Serafim; KOTZE, Paulo Gustavo; SAAD-HOSSNE, Rogério

doi:10.1590/S0004-2803.2022005S1-01

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ORIGINAL ARTICLE • Arq. Gastroenterol. 59 (suppl 1) • 2022 • https://doi.org/10.1590/S0004-2803.2022005S1-01 linkcopy

SURGICAL MANAGEMENT OF ADULT CROHN’S DISEASE AND ULCERATIVE COLITIS PATIENTS: A CONSENSUS FROM THE BRAZILIAN ORGANIZATION OF CROHN’S DISEASE AND COLITIS (GEDIIB)

Tratamento cirúrgico de pacientes adultos com doença de Crohn e retocolite ulcerativa: um consenso da Organização Brasileira de Doença de Crohn e Colite (GEDIIB)

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Background: Despite optimized medical therapy, contemporary risk of surgery in inflammatory bowel diseases (IBD) after 10 years of diagnosis is 9.2% in patients with ulcerative colitis (UC) and 26.2% in Crohn’s disease, (CD) in the biological era.

Objective: This consensus aims to detail guidance to the most appropriate surgical procedures in different IBD scenarios. In addition, it details surgical indications and perioperative management of adult patients with CD and UC.

Methods: Our consensus was developed by colorectal surgeons and gastroenterologists representing the Brazilian Study Group of Inflammatory Bowel Diseases (GEDIIB), with the Rapid Review methodology being conducted to support the recommendations/statements. Surgical recommendations were structured and mapped according to the disease phenotypes, surgical indications, and techniques. After structuring the recommendations/statements, the modified Delphi Panel methodology was used to conduct the voting by experts in IBD surgery and gastroenterology. This consisted of three rounds: two using a personalized and anonymous online voting platform and one face-to-face presential meeting. Whenever participants did not agree with specific statements or recommendations, an option to outline possible reasons was offered to enable free-text responses and provide the opportunity for the experts to elaborate or explain disagreement. The consensus of recommendations/statements in each round was considered to have been reached if there was ≥80% agreement.

Results and conclusion: This consensus addressed the most relevant information to guide the decision-making process for adequate surgical management of CD and UC. It synthesizes recommendations developed from evidence-based statements and state-of-art knowledge. Surgical recommendations were structured and mapped according to the different disease phenotypes, indications for surgery and perioperative management. Specific focus of our consensus was given to elective and emergency surgical procedures, determining when to indicate surgery and which procedures may be the more appropriate. The consensus is targeted to gastroenterologists and surgeons interested in the treatment and management of adult patients with CD or UC and supports decision-making of healthcare payors, institutional leaders, and/or administrators.

Keywords:
Crohn’s disease; ulcerative colitis; surgery; adults; inflammatory bowel diseases; disease management

Disease	Search strategy	Results (titles)
DC	(“inflammatory bowel disease “[Title] OR “IBD” [Title/Abstract] OR “Crohn” [Title] OR “DC” [Title/Abstract]) AND (“treatment” OR “management” OR “surgery” OR “surgical”) AND (“consensus” [Title] OR “guidelines” [Title]) AND ((y_5 [Filter]) AND (English [Filter]))	119
UC	(“inflammatory bowel disease” [Title] OR “IBD” [Title/Abstract] OR “ulcerative colitis” [Title] OR “UC” [Title/Abstract]) AND (“treatment” OR “management” OR “surgery” OR “surgical”) AND (“consensus” [Title] OR “guidelines” [Title]) AND ((y_5 [Filter]) AND (English [Filter]))	103

Authors	Title	Domain 1 score	Domain 2 score	Domain 3 score	Domain 4 score	Domain 5 score	Domain 6 score	Overall assessment
Adamina et al., 2020	ECCO guidelines on therapeutics in crohn’s disease: surgical treatment	100.0	61.1	87.5	100.0	8.3	100.0	76.2
Bemelman et al., 2017	ECCO-ESCP consensus on surgery for Crohn’s disease	66.7	61.1	81.3	100.0	33.3	100.0	73.7
Biroulet et al., 2016	French national consensus clinical guidelines for the management of Crohn’s disease	66.7	61.1	33.3	83.3	0.0	50.0	49.1
Bouchard et al., 2018	Management of anoperineal lesions in Crohn’s disease: a French National Society of Coloproctology national consensus	66.7	66.7	54.2	100.0	8.3	50.0	57.6
Brown et al., 2018	The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease	66.7	66.7	87.5	100.0	50.0	100.0	78.5
Choi et al., 2017	Second Korean guidelines for the management of ulcerative colitis.	72.2	38.9	68.8	77.8	37.5	58.3	58.9
de Simone et al., 2021	WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting	100.0	66.7	72.9	94.4	45.8	100.0	80.0
Gionchetti et al., 2016	3rd European evidence-based consensus on the diagnosis and management of Crohn’s disease 2016: part 2: surgical management and special situations.	66.7	61.1	87.5	100.0	8.3	100.0	70.6
Holubar et al.,	The American Society of Colon and rectal surgeons clinical practice guidelines for the surgical management of ulcerative colitis.	66.7	66.7	87.5	100.0	50.0	100.0	78.5
Lamb et al., 2019	British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults	100.0	100.0	100.0	100.0	95.8	100.0	99.3
Lee et al., 2017	Association of coloproctology of Great Britain and Ireland Consensus Exercise on Surgical Management of Fistulating Perianal Crohn’s Disease	66.7	66.7	14.6	61.1	0.0	100.0	51.5
Lightner et al., 2020	The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Crohn’s Disease	66.7	66.7	89.6	94.4	54.2	100.0	78.6
Magro et al., 2017	Third European Evidence-based Consensus on diagnosis and management of ulcerative colitis. Part 1: definitions, diagnosis, extra-intestinal manifestations, pregnancy, cancer surveillance, surgery, and ileo-anal pouch disorders.	77.8	61.1	70.8	88.9	62.5	83.3	74.1
Matsuoka et al., 2018	Evidence-based clinical practice guidelines for inflammatory bowel disease	83.3	61.1	66.7	83.3	50.0	66.7	68.5
Park et al., 2018	Second Korean guidelines for the management of Crohn’s disease	88.9	72.2	85.4	88.9	58.3	58.3	75.3
Sood et al., 2019	Diet and inflammatory bowel disease: the Asian Working Group guidelines	66.7	50.0	27.1	61.1	0.0	50.0	42.5
Spinelli et al., 2021	ECCO Guidelines on therapeutics in ulcerative colitis: surgical treatment.	100.0	61.1	87.5	100.0	8.3	100.0	76.2
Steinhart et al., 2019	Clinical practice guideline for the medical management of perianal fistulizing Crohn’s Disease: the Toronto Consensus	77.8	72.2	79.2	72.2	66.7	83.3	75.2
Wei et al., 2017	Management of Crohn’s disease in Taiwan: consensus guideline of the Taiwan Society of Inflammatory Bowel Disease	55.6	38.9	25.0	61.1	37.5	8.3	37.7

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Instituto Brasileiro de Estudos e Pesquisas de Gastroenterologia e Outras Especialidades - IBEPEGE. Rua Dr. Seng, 320, 01331-020 São Paulo - SP Brasil, Tel./Fax: +55 11 3147-6227 - São Paulo - SP - Brazil
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[TFN1] Question: What are the criteria for indication of elective surgery in abdominal CD in adults, according to international guidelines and/or consensus?

P	Adults (≥18 years) with abdominal CD
I	Elective surgery
C	Not applicable
O	Criteria for indication of elective surgery
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with abdominal CD
I	Surgical management
C	Not applicable
O	• Nutrition
	• Prophylaxis of venous thromboembolism events (VTE)
	• Sepsis control
	• Corticosteroids
	• Immunosuppressants
	• Anti-TNF
	• Anti-integrin
	• Anti-interleukin
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with luminal CD of small intestine and colonic
I	Management of perianal or rectovaginal fistulizing disease
C	Not applicable
O	• Management of intra-abdominal abscess
	• Percutaneous drainage guided by imaging
	• Clinical treatment of intra-abdominal abscess
	• Surgical treatment of intra-abdominal abscess
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with small bowel and colonic CD
I	Management of Stenosing CD
C	Not applicable
O	• Endoscopic treatment
	• Surgical Treatment (Stenoplasty and Resection)
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with small bowel and colonic CD
I	Management of CD - Anal stenosing disease
C	Not applicable
O	• Clinical and surgical treatment of anal stenosing disease
Type of study	International guidelines and/or consensus published after 2016º

P	Adults (≥18 years) with small bowel and colonic abdominal CD with acute appendicitis
I	Management of Crohn’s disease as an incidental finding of appendicitis.
C	Not applicable
O	Clinical and surgical treatment of CD as an incidental finding of acute appendicitis
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with luminal CD
I	Elective surgery for disease with complex perianal fistula
C	Not applicable
O	Surgical techniques for disease with complex perianal fistula
	• Seton placement
	• Endoanal flap advancement
	• Fibrin glue
	• LIFT (Ligation of the intersphincteric fistula tract)
	• Anal plug
	• VAAFT (Video-assisted anal fistula treatment)
	• FILAC Laser (laser closure tract)
	• Stem Cells: allogeneic and autologous
	• Intestinal diversion
	• Total proctocolectomy with ileostomy
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with perianal fistulizing CD
I	Refractory pelvic sepsis treatment
C	Not applicable
O	• Clinical and surgical treatment of refractory pelvic sepsis
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with active UC
I	Elective surgery
C	Not applicable
O	Eligibility criteria for indication of elective surgery
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with refractory moderate to severe UC
I	Perioperative management
C	Not applicable
O	• Nutrition
	• Prophylaxis of VTE
	• Corticosteroids
	• Immunosuppressants
	• Anti-TNF
	• Anti-integrin
	• Anti-interleukin
	• JAK inhibitors
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with severe UC
I	Not applicable
C	Not applicable
O	Complications related to the ileal pouch:
	• Fistulas and dehiscence of anastomosis
	• Pouchitis (acute, chronic, and refractory)
	• Ileoanal pouch failure
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with ASC
I	Urgent and emergency surgery
C	Not applicable
O	Criteria for indication of urgent and emergency surgery
Type of study	International guidelines and/or consensus published after 2016