On the cutting edge of pathology and surgery

There is no place for the pathologist in the operating room or for the surgeon at the microscope, argued pathologist Prof. Paula Borralho Nunes (University of Lissabon, Portugal) and surgeon Prof. Antonino Spinelli (Humanitas Research Hospital, Italy) at a tandem talk on pathology-guided surgery. However, the diagnosis and correct management of inflammatory bowel disease (IBD) demands multidisciplinary teamwork, and the 2 speakers agreed that the surgeon and pathologist should meet before (especially to discuss pouch surgery and dysplasia), during (in case of suspicion for malignancies), and after surgery.

Prof. Borralho Nunes and Prof. Spinelli discussed how the pathologist might support the surgeon in order to reshape surgery for IBD and achieve better results.

First, pathology plays a major part in the diagnostic process, and a correct diagnosis has a major impact on the choice between surgical options. Additionally, the analysis of histological features can predict post-operative recurrence. So, for example, pathology is crucial in the selection of pouch candidates. A meta-analysis of 17 studies revealed that patients with indeterminate colitis (IC) –or rather IBD unclassified (IBDU)– had a higher anastomotic leak rate and a higher overall complication rate than patients with ulcerative colitis (UC) [1]. In IC patients, subtotal colectomy may therefore generally be a better option. This allows for pathological reassessment, as well as discussion within a multi-disciplinary team and with the patient about options and risks, before making a final surgical decision.

Another subject on the 'cutting edge' of pathology and surgery is the evaluation of disease activity at resection margin in Crohn's Disease (CD). Several studies were highlighted to illustrate the importance.

• The presence of involved histological margins has been associated with a higher risk of recurrence [2].
• Patients with transmural lesions at the ileal margin were shown to have an increased risk of post-operative recurrence versus patients without these lesions (75% vs 46%), which is why histologic features of the ileal margin should be considered when discussing post-operative therapy [3].
• Submucosal lymphocytic plexitis in the proximal surgical margin has been significantly associated with a higher risk of endoscopic recurrence of CD after ileocolonic resection [4].
• Increased enteric glial cells in the proximal margin of resection have been associated with postoperative recurrence of CD [5].
• Granulomatous CD has been associated with a higher risk as well as a shorter time to recurrence and reoperation [6].

Prof. Borralho Nunes and Prof. Spinelli ended their talk by emphasising the need to standardise reporting on IBD surgical specimens. Summarised reports following a prespecified scheme will facilitate completeness and communication. Publication of the ECCO Topical Review 'Optimising reporting on surgery, endoscopy and histopathology' is scheduled for late 2020.

1. 
   
   1. Emile SH, et al. J Crohns Colitis. 2020 Jan 8. pii: jjaa002.
   2. Ryan JM, et al. Dis Colon Rectum. 2019 Jul;62(7):882-892
   3. Hammoudi N, et al. Clin Gastroenterol Hepatol. 2020;18(1):141-9.
   4. Lemmens B, et al. J Crohns Colitis. 2017;11(2):212-20.
   5. Li Y, et al. J Gastroenterol Hepatol. 2018;33(3):638-44.
   6. Simillis C, et al. Dis Colon Rectum. 2010;53(2):177-85.

 



Posted on 14 April, 20208 April, 2024