P564 Surgical treatment of jejuno-ileal Crohn’s disease. Results from the The JejUno Ileal Crohn's disEase (JUICE) international, multicentric, observational study
Authors: Baldi C , Mineccia M , Ferrero A , Di Benedetto M , Spinelli A , Scarpa M , Angriman I , Cricrì M , Luglio G , Colombo F , Danelli P , Bislenghi G , D'Hoore A , Nasasra A , Warusavitarne J , Manzo C A , Celentano V , Marti-Gallostra M , Espin Basany E , Schena C A , Pellino G , De Angelis N , Rottoli M , Poggioli G , Sampietro G M 
Published: January 2024

Abstract

Background
Crohn’s disease (CD) affecting the upper gastrointestinal (GI) tract is a rare condition, leading to a scarcity of information regarding its diagnosis, surgical treatment, and adjuvant therapy. The JUICE study aimed to conduct a surgical audit of duodeno-jejuno-ileal CD across 11 European IBD Referral Centres.

Methods
The study included all the consecutive, non-selected patients undergoing surgery for upper-GI CD between January 2010 and December 2022. Patients with synchronous ileal and colonic locations were included, while those with previous upper-GI CD surgery or multiple surgeries for ileo-colic CD were excluded. Univariate and multivariate analyses of 120 variables, covering pre-operative characteristics, intra-operative findings, and post-operative follow-up, were conducted.

Results
The study encompassed 279 patients, with a male/female ratio of 2.2. The average age at diagnosis was 30±14 years, and the disease duration was 11±10 years. The Montreal Classification revealed A1 15.4%, A2 61.3%, A3 23.3%; L1+L4 34.4%, L2+L4 4%, L3+L4 26.9%, isolated L4 34%; B1 1.8%, B2 67.4%, B3 30.8%; perianal location 19.4%. BMI averaged 21±3. Preoperative nutritional support was necessary in 50.5%. MRI-enterography was the predominant preoperative examination (86.7%). Comorbidities were present in 24.7%, with 61% having an ASA score &gt;1. In the 30 days pre-surgery, 16.8% used steroids, 41.2% received biologicals, with 24.6% on combined (biologicals + steroids) therapy. Video-assisted approach was used in 70%, with a 5.1% conversion rate. Intraoperative staging revealed 1334 locations treated with 247 resections, 500 strictureplasties, 12 bypasses, and 53 concomitant colonic resections. Entero-enteric fistulas and intra-abdominal abscesses were present in 29% and 14%. Patients with thickened mesentery, wrapping fat, and lymph node enlargement were 50.8%, 38.7%, and 50.8%, respectively. Mortality was 1%, Clavien-Dindo grade 3 and 4 complication rate 11.1%. Hospital stay averaged 10±6 days; 90-day readmission was 3.2%. B3 behaviour, smoking, preoperative malnutrition, and preoperative biological therapy increased postoperative complication risk (p=0.01). 10-year Kaplan-Meier surgical recurrence rate was 23%, reduced to 11% with early and continuous post-op biologic treatment compared to late treatment or suspension (60% - Log-Rank p&lt;0.0001).

Conclusion
This is by far the largest series of upper-GI CD ever studied, depicting a little known, complex, technically demanding sub-group of patients. Preoperative optimization, focusing on preoperative nutritional status and therapy, is crucial to reduce complication risk. Early-onset post-operative biological therapy seems to significantly reduce long-term surgical recurrence.