Introduction:
The majority of Crohn’s disease (CD) patients will require surgery, and strategies to reconstruct the bowel may include side-to-side anastomosis (STSA) and end-to-end anastomosis (ETEA), which are left to the discretion of the operating surgeon. There is debate regarding the optimal anastomotic configuration and limited data regarding differential clinical outcomes beyond two years. Previous literature has suggested that ETEA restores the intestine anatomically and physiologically as an intact “tube” but is more technically challenging to construct than the STSA, which transects circular muscle layers and creates an aperistaltic reservoir at the anastomotic segment. We sought to evaluate long-term outcomes beyond two years, comparing ETEA vs STSA for CD patients in a real-world setting, with a focus on long-term patterns of healthcare utilization and quality of life (QoL).

Methods: A prospective cohort of CD patients with intestinal anastomosis performed between 2009 and 2017 and consistent 5-year follow-ups were selected from a consented natural history registry at a tertiary referral hospital. Demographic data, QoL scores (Short Inflammatory Bowel Disease Questionnaire), disease activity scores (Harvey Bradshaw Index), healthcare utilization, medication use, and need for repeat resection were collected for the 5-year observation period.

Results: Among 278 post-operative CD patients, 152 had ETEA and 126 had STSA. There was no difference in age, gender, and medical treatment over the 5 years between the two groups. In the 5-year post-op observation period, ETEA patients demonstrated better QoL compared with STSA (SIBDQ 51.1 ± 12.5 SD vs. 47.4 ± 13.8 SD, p=0.03). ETEA patients had fewer repeat resections compared with STSA (11.2% vs. 25.4%; p=0.002). Kaplan-Meier analysis showed higher mean survival days without re-operation in ETEA patients (ETEA 1803.3 ± 26.3 vs. STSA 1681.2 ± 44.2, p=0.008). ETEA CD patients had a decreased need for hospitalization compared with STSA patients (p=0.05), but there was no difference in disease activity, emergency room (ER) visits, and CT scans during the 5-year observation period.

Conclusion: These long-term, 5-year postoperative follow-up data suggest that in a real-world setting, ETEA is superior to STSA for CD patients undergoing small bowel resection and re-anastomosis. CD patients with ETEA demonstrated sustained, better quality of life and reduced need for reoperation, despite having similar medication treatment and disease activity compared with STSA CD patients over 5 years.

Survival to repeat resection

Marc Schwartz

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