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Lee KE, Cantrell S, Shen B, Faye AS. Post-operative prevention and monitoring of Crohn's disease recurrence. Gastroenterol Rep (Oxf) 2022; 10:goac070. [PMID: 36405006 PMCID: PMC9667961 DOI: 10.1093/gastro/goac070] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 10/22/2023] Open
Abstract
Crohn's disease (CD) and ulcerative colitis (UC) are relapsing and remitting chronic inflammatory diseases of the gastrointestinal tract. Although surgery for UC can provide a cure, surgery for CD is rarely curative. In the past few decades, research has identified risk factors for postsurgical CD recurrence, enabling patient risk stratification to guide monitoring and prophylactic treatment to prevent CD recurrence. A MEDLINE literature review identified articles regarding post-operative monitoring of CD recurrence after resection surgery. In this review, we discuss the evidence on risk factors for post-operative CD recurrence as well as suggestions on post-operative management.
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Affiliation(s)
- Kate E Lee
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Sarah Cantrell
- Duke University Medical Center Library & Archives, Duke University School of Medicine, Durham, NC, USA
| | - Bo Shen
- Center for Inflammatory Bowel Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Adam S Faye
- Division of Gastroenterology, NYU Grossman School of Medicine, New York, NY, USA
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Abstract
Treatment of Crohn's disease (CD) focuses on providing acceptable quality of life for the affected individual by optimizing medical therapy, endoscopic procedures, and surgical intervention. Biologics have changed the medical management of moderate to severe CD. However, despite their introduction, the need for surgical resection in CD has not drastically changed, with two-thirds of the patients still requiring an intestinal resection. Patient outcomes are optimized by focusing on preoperative management and intraoperative technical aspects to maximize bowel preservation. This article reviews some of the important principles of Crohn's surgery to help guide surgeons when approaching this challenging patient population.
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Affiliation(s)
- Valery Vilchez
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA; Center for Regenerative Medicine and Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA; Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA; Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA; Center for Immunotherapy, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
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Reynolds IS, Doogan KL, Ryan ÉJ, Hechtl D, Lecot FP, Arya S, Martin ST. Surgical Strategies to Reduce Postoperative Recurrence of Crohn's Disease After Ileocolic Resection. Front Surg 2021; 8:804137. [PMID: 34977147 PMCID: PMC8718441 DOI: 10.3389/fsurg.2021.804137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/30/2021] [Indexed: 11/13/2022] Open
Abstract
Postoperative recurrence after ileocaecal resection for fibrostenotic terminal ileal Crohn's disease is a significant issue for patients as it can result in symptom recurrence and requirement for further surgery. There are very few modifiable factors, aside from smoking cessation, that can reduce the risk of postoperative recurrence. Until relatively recently, the surgical technique used for resection and anastomosis had little or no impact on postoperative recurrence rates. Novel surgical techniques such as the Kono-S anastomosis and extended mesenteric excision have shown promise as ways to reduce postoperative recurrence rates. This manuscript will review and discuss the evidence regarding a range of surgical techniques and their potential role in reducing disease recurrence. Some of the techniques have been shown to be associated with significant benefits for patients and have already been integrated into the routine clinical practice of some surgeons, while other techniques remain under investigation. Current techniques such as resection of the mesentery close to the intestine and stapled side to side anastomosis are being challenged. It is looking more likely that surgeons will have a major role to play when it comes to reducing recurrence rates for patients undergoing ileocaecal resection for Crohn's disease.
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Affiliation(s)
- Ian S. Reynolds
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland
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Mir A, Nguyen VQ, Soliman Y, Sorrentino D. Wireless Capsule Endoscopy for Diagnosis and Management of Post-Operative Recurrence of Crohn's Disease. Life (Basel) 2021; 11:life11070602. [PMID: 34201514 PMCID: PMC8303387 DOI: 10.3390/life11070602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/07/2021] [Accepted: 06/21/2021] [Indexed: 02/07/2023] Open
Abstract
Despite aggressive medical therapy, many patients with Crohn's disease require surgical intervention over time. After surgical resection, disease recurrence is common. Ileo-colonoscopy and the Rutgeerts score are commonly used for diagnosis and monitoring of post-operative endoscopic recurrence. The latter is the precursor of clinical recurrence and therefore it impacts prognosis and patient management. However, due to the limited length of bowel assessed by ileo-colonoscopy, this procedure can miss out-of-reach, more proximal lesions in the small bowel. This limitation introduces an important uncertainty when evaluating post-operative relapse by ileo-colonoscopy. In addition, the Rutgeerts score 'per se' bears a number of ambiguities. Here we will discuss the pros and cons of ileo-colonoscopy and other imaging studies including wireless capsule endoscopy to diagnose and manage post-operative recurrence of Crohn's disease. A number of studies provide evidence that wireless capsule endoscopy is a potentially more accurate as well as less invasive and less costly alternative to conventional techniques including ileo-colonoscopy.
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Affiliation(s)
- Adil Mir
- IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of Medicine, Roanoke, VA 24016, USA; (A.M.); (V.Q.N.); (Y.S.)
| | - Vu Q. Nguyen
- IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of Medicine, Roanoke, VA 24016, USA; (A.M.); (V.Q.N.); (Y.S.)
| | - Youssef Soliman
- IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of Medicine, Roanoke, VA 24016, USA; (A.M.); (V.Q.N.); (Y.S.)
| | - Dario Sorrentino
- IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of Medicine, Roanoke, VA 24016, USA; (A.M.); (V.Q.N.); (Y.S.)
- Department of Clinical and Experimental Medical Sciences, University of Udine School of Medicine, 33100 Udine, Italy
- Correspondence:
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Rönnblom A, Karlbom U. Clinical course of Crohn's disease in a population-based cohort in Uppsala County followed for 10 years. Scand J Gastroenterol 2020; 55:1301-1307. [PMID: 33016802 DOI: 10.1080/00365521.2020.1829700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS There is a shortage of studies describing the outcome of patients with Crohn's disease (CD) where both biological therapy and immunomodulators (IMMs) have been available. The aim of the present study was to describe the clinical course of the disease, the use of drugs, the need for surgery and mortality in a prospectively recruited population-based cohort of patients followed for 10 years. METHODS All patients diagnosed with CD in the County of Uppsala in Sweden 2005-2009 were prospectively recruited and followed until the end of 2019. The medical notes were scrutinised and relevant information collected. RESULTS One hundred and fifty-four patients covering all age groups were diagnosed with CD and 145 (94.2%) could be followed for 10 years or until death. Nine patients were lost to follow up. The following drugs were used: 5-ASA 83%, steroids 84%, IMMs 69% and biologicals 23%. The proportion of penetrating disease increased from 9.7 to 14.5%. Primary bowel resections were performed in 22% of the patients, and none of these had any secondary surgery because of recurrent or progressive disease during the observation time. Twelve patients (7.8%) died during the follow up, and one of these because of a small bowel carcinoma. CONCLUSIONS In the present study, the clinical course of CD was similar to previous reports during the first year after diagnosis, but the following years were considerably more stable with moderate increase of intestinal damage and totally a low frequency of surgery and no repeated surgery.
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Affiliation(s)
- Anders Rönnblom
- Department of Medical Sciences, Uppsala University, University Hospital, Uppsala, Sweden
| | - Urban Karlbom
- Department of Surgical Sciences, Uppsala University, University Hospital, Uppsala, Sweden
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Levin A, Risto A, Myrelid P. The changing landscape of surgery for Crohn's disease. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Landerholm K, Kalman D, Wallon C, Myrelid P. Immunomodulators: Friends or Enemies in Surgery for Crohn’s Disease? Curr Drug Targets 2019; 20:1384-1398. [DOI: 10.2174/1389450120666190617163919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/18/2019] [Accepted: 04/25/2019] [Indexed: 02/08/2023]
Abstract
Crohn’s disease may severely impact the quality of life and being a chronic disease it requires
both medical and surgical treatment aimed at induction and maintenance of remission to prevent
relapsing symptoms and the need for further surgery. Surgery in Crohn’s disease often has to be
performed in patients with well-known risk factors of post-operative complications, particularly intraabdominal
septic complications. This review will look at the current knowledge of immunomodulating
therapies in the peri-operative phase of Crohn’s disease. The influence of immunomodulators on postoperative
complications is evaluated by reviewing available clinical reports and data from animal
studies. Furthermore, the effect of immunomodulators on preventing or deferring primary as well as
repeat surgery in Crohn’s disease is reviewed with particular consideration given to high-risk cohorts
and timing of prophylaxis.
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Affiliation(s)
- Kalle Landerholm
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, Ryhov County Hospital, Jonkoping, Sweden
| | - Disa Kalman
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
| | - Conny Wallon
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
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Hendel K, Kjærgaard S, El-Hussuna A. A systematic review of pre, peri and postoperative factors and their implications for the lengths of resected bowel segments in patients with Crohn’s disease. INTERNATIONAL JOURNAL OF SURGERY OPEN 2017; 7:10-16. [DOI: 10.1016/j.ijso.2017.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Abstract
Aim
Several pre, peri and postoperative factors may have implications for the lengths of resected small bowel segments in Crohn’s disease patients. It might also affect patient outcome. We reviewed the current literature on factors and their implications for the lengths of resected small bowel segments and possible correlations with postoperative outcome.
Method
Searches were independently engineered by the authors and a research-librarian in MEDLINE and OVID databases using PubMed and EMBASE engines in compliance with PRISMA recommendations. All original articles, reviews and guidelines published in the period of 1985–2016 with last search date 13th of February 2016 on bowel resection in Crohn’s disease patients were assessed for inclusion.
Results
We identified 52 studies for synthesis. Preoperative: Perforation as indication for surgery and increased visceral obesity may be factors resulting in longer lengths of resected small bowel segments. Administration of total parenteral nutrition might reduce resection lengths. Perioperative: No difference in resection lengths in elective versus acute surgery, laparoscopic versus open approaches or in case of intra-operative blood transfusions. Stapled anastomoses might conserve more bowel than sutured ones. Postoperative: The lengths of the resected small bowel segments most likely have no impact on recurrence rates.
Conclusion
No pre, peri or postoperative factors were found to have definitive implications for the lengths of resected small bowel segments. Correlation between the lengths of resection and recurrence is weak.
Highlights
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Lee JL, Yu CS, Lim SB, Park IJ, Yoon YS, Kim CW, Yang SK, Kim JC. Surgical Treatment of Crohn Colitis Involving More Than 2 Colonic Segments: Long-Term Outcomes From a Single Institution. Medicine (Baltimore) 2016; 95:e3793. [PMID: 27258512 PMCID: PMC4900720 DOI: 10.1097/md.0000000000003793] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 04/29/2016] [Accepted: 05/04/2016] [Indexed: 12/13/2022] Open
Abstract
The incidence of primary Crohn colitis is uncommon and surgical treatment has remained controversial, although most patients with Crohn colitis eventually require surgical intervention. This study aims to compare the operative outcomes of patients who underwent segmental versus either total colectomy or total proctocolectomy for Crohn colitis and to assess potential risk factors associated with clinical and surgical recurrence-free survivals.This is a retrospective study of 116 patients who underwent primary surgery for Crohn colitis between August 1997 and July 2011. Patients were classified based on the type of surgery: segmental colectomy (SC group; n = 71) or either total colectomy or total proctocolectomy (TC group; n = 45).There were no significant differences in postoperative complications or the nutritional state between the SC and TC groups. Patients in TC group had a significantly higher clinical recurrence-free survival (CRFS). Among the 54 patients with multisegmental Crohn colitis, the TC group had a significantly increased CRFS and surgical recurrence-free survival (SRFS), compared with patients in the SC group (5-year CRFS: 82.0% ± 5.8% vs 22.2% ± 13.9%, P = 0.001; 5-year SRFS: 88.1% ± 5.0% vs 44.4% ± 16.6%, P = 0.001). By multivariate analysis of patients with multisegments involved, SC was a risk factor for SRFS and CRFS (hazard ratio [HR] = 4.637, 95% confidence interval [CI] = 1.387-15.509, P = 0.013 and HR = 32.407, 95% CI = 2.873-365.583, P = 0.005).TC patients have significantly increased CRFS and TC in patients with multisegment involvement may affect improved SRFS and CRFS. Among patients with multisegmental Crohn colitis, SC is an independent risk factor for CRFS and SRFS.
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Affiliation(s)
- Jong Lyul Lee
- From the Department of Surgery, Division of Colon and Rectal Surgery (JLL, CSY, S-BL, IJP, YSY, CWK, JCK); and Department of Gastroenterology (S-KY), University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Handler M, Dotan I, Klausner JM, Yanai H, Neeman E, Tulchinsky H. Clinical recurrence and re-resection rates after extensive vs. segmental colectomy in Crohn's colitis: a retrospective cohort study. Tech Coloproctol 2016; 20:287-292. [PMID: 26886936 DOI: 10.1007/s10151-016-1440-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 01/23/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of the present study was to document long-term clinical recurrence and re-resection rates of segmental and extended colectomy in patients with Crohn's colitis and to identify risk factors causing recurrence. METHODS Records of patients with isolated colonic Crohn's disease who underwent colectomy between 1995 and 2013 and were followed at our medical center were identified. Data on age at diagnosis, gender, smoking, disease location at diagnosis, perianal and rectal disease, indication for surgery, preoperative disease duration, type of operation, primary anastomosis at first operation, length of resected specimen, recurrence of symptoms, postoperative medication, reoperation, and total follow-up time were retrieved. RESULTS Thirty-five suitable patients (18 segmental colectomy, 17 extensive colectomy; 17 males; mean age at operation 36.6 years) were identified. Mean age at primary operation was 36 years. The mean preoperative disease duration was 121 months. Postoperative medical treatment was needed in 10 (56 %) patients undergoing segmental colectomy and in 16 (94 %) of those undergoing extensive colectomy (p = 0.01). There was longer reoperation-free survival in the segmental colectomy patient group (p = 0.02) and also a trend toward longer symptom-free survival compared to the extensive colectomy patient group (p = 0.105). There was no correlation between the length of resected bowel and recurrence. Patients operated on at a younger age did not have a higher rate of recurrence of symptoms. Shorter disease duration, smoking, and male gender were risk factors for clinical recurrence. CONCLUSIONS Segmental resection with primary anastomosis can be safely performed in patients with limited Crohn's colitis with reasonable clinical recurrence rates.
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Affiliation(s)
- M Handler
- Colorectal Unit, Division of Surgery, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv Medical Center, Tel-Aviv University, 6 Weizman Street, 6423906, Tel-Aviv, Israel
| | - I Dotan
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel-Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - J M Klausner
- Colorectal Unit, Division of Surgery, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv Medical Center, Tel-Aviv University, 6 Weizman Street, 6423906, Tel-Aviv, Israel
| | - H Yanai
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel-Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - E Neeman
- Colorectal Unit, Division of Surgery, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv Medical Center, Tel-Aviv University, 6 Weizman Street, 6423906, Tel-Aviv, Israel
| | - H Tulchinsky
- Colorectal Unit, Division of Surgery, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv Medical Center, Tel-Aviv University, 6 Weizman Street, 6423906, Tel-Aviv, Israel.
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Endoscopic Versus Histological Disease Extent at Presentation of Paediatric Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2016; 62:246-51. [PMID: 26545202 DOI: 10.1097/mpg.0000000000001032] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The Paris classification (PC) of paediatric inflammatory bowel disease categorises disease extent and therefore affects treatment decisions. Histological (microscopic) disease extent is not incorporated, and endoscopic (macroscopic) findings may underrepresent disease extent when compared with histological findings; this study compares disease extent at presentation. METHODS Data were obtained of patients <17 years of age diagnosed with inflammatory bowel disease from 2010 to 2013 at University Hospital Southampton. Data are presented as percentage of patients undergoing endoscopy. PC was performed alongside a modified PC by histological disease location. RESULTS A total of 172 patients were identified (median age at diagnosis 13.5 years, 115 boys); Crohn disease (CD) 107, ulcerative colitis (UC) 50, inflammatory bowel disease unclassified (IBDU) 15; 159 had undergone upper gastrointestinal (GI) endoscopy, 163 had undergone lower GI endoscopy. Histological disease was more extensive at all points for CD, UC, and IBDU. CD--endoscopic ileal disease in 49% of patients compared with histological disease in 71.3%. Comparing PC--a 10% increase in L3 disease (ileocolonic), a 24% increase in L3 + L4a disease (ileocolonic plus upper GI), and a 27% increase in all of the upper GI involvement if histological disease extent was used. UC--the most common disease location was the rectum (endoscopic 91.5% vs histological 93.6%) and descending colon (endoscopic 89.4% vs histological 95.7%). Comparing PC--a 19% increase in E4 disease (pancolitis) if histological disease extent was used. CONCLUSIONS These data confirm that histological disease extent is greater than endoscopic disease extent. This should be considered when the PC is used. Further study is needed to elucidate which classification would better predict disease outcome.
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Presence of Granulomas in Mesenteric Lymph Nodes Is Associated with Postoperative Recurrence in Crohn's Disease. Inflamm Bowel Dis 2015. [PMID: 26218143 DOI: 10.1097/mib.0000000000000541] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The association between the presence of granulomas in the mesenteric lymph node (MLN) and postoperative recurrent Crohn's disease (CD) is unknown. Our aim was to assess the predictive value of the presence of granulomas in MLN as well as in bowel wall for postoperative recurrence of CD. METHODS Patients with CD who underwent the index ileocolonic resection between 2004 and 2012 were included. Surgical pathology reports were reviewed for the presence and location of granulomas. The status of MLN granulomas was confirmed by re-review of surgical pathology specimen from randomly sampled patients by an expert pathologist. Both univariable and multivariable analyses were performed to assess the risk factors associated with postoperative recurrent CD. RESULTS A total of 194 patients were included. Granulomas were detected in the MLN in 23 patients (11.9%), and in the intestinal wall in 57 (29.4%). On Kaplan-Meier curve, the presence of granulomas in MLN was found to be a risk factor for postoperative endoscopic recurrence (P = 0.015) as well as surgical recurrence (P = 0.035). In contrast, granulomas in the bowel wall, which was not found to be associated with neither endoscopic recurrence (P = 0.94) or surgical recurrence (P = 0.56). On Cox proportional hazards regression analysis, the presence of MLN granulomas was independently associated with an increased risk for both postoperative endoscopic recurrence (hazard ratio [HR] = 1.91; 95% confidence interval [CI], 1.06-3.45; P = 0.031) and surgical recurrence (HR = 3.43; 95% CI, 1.18-9.99; P = 0.023). CONCLUSIONS The presence of granulomas in MLN but not in intestine per se was found to be an independent risk factor for recurrence in CD patients undergoing ileocolonic resection.
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Manser CN, Frei P, Grandinetti T, Biedermann L, Mwinyi J, Vavricka SR, Schoepfer A, Fried M, Rogler G. Risk factors for repetitive ileocolic resection in patients with Crohn's disease: results of an observational cohort study. Inflamm Bowel Dis 2014; 20:1548-54. [PMID: 25036758 DOI: 10.1097/mib.0000000000000123] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgical recurrence rates among patients with Crohn's disease with ileocolic resection (ICR) remain high, and factors predicting surgical recurrence remain controversial. We aimed to identify risk and protective factors for repetitive ICRs among patients with Crohn's disease in a large cohort of patients. METHODS Data on 305 patients after first ICR were retrieved from our cross-sectional and prospective database (median follow-up: 15 yr [0-52 yr]). Data were compared between patients with 1 (ICR = 1, n = 225) or more than 1 (ICR >1, n = 80) resection. Clinical phenotypes were classified according to the Montreal Classification. Gender, family history of inflammatory bowel disease, smoking status, type of surgery, immunomodulator, and biological therapy before, parallel to and after first ICR were analyzed. RESULTS The mean duration from diagnosis until first ICR did not differ significantly between the groups, being 5.93 ± 7.65 years in the ICR = 1 group and 5.36 ± 6.35 years in the ICR >1 group (P = 0.05). Mean time to second ICR was 6.7 ± 5.74 years. In the multivariate logistic regression analysis, ileal disease location (odds ratio [OR], 2.42; 95% confidence interval [CI], 1.02-5.78; P = 0.05) was a significant risk factor. A therapy with immunomodulators at time of or within 1 year after first ICR (OR, 0.23; 95% CI, 0.09-0.63; P < 0.01) was a protective factor. Neither smoking (OR, 1.16; 95% CI, 0.66-2.06) nor gender (male OR, 0.85; 95% CI, 0.51-1.42) or family history (OR, 1.68; 95% CI, 0.84-3.36) had a significant impact on surgical recurrence. CONCLUSIONS Immunomodulators have a protective impact regarding surgical recurrence after ICR. In contrast, ileal disease location constitutes a significant risk factor for a second ICR.
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Affiliation(s)
- Christine N Manser
- *Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland; †Gastroenterology Unit, Clinic of Internal Medicine, See-Spital, Horgen, Switzerland; ‡Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland; §Department of Gastroenterology and Hepatology, Triemlispital Zurich, Zurich, Switzerland; and ‖Division of Gastroenterology and Hepatology, University Hospital Lausanne/CHUV, Lausanne, Switzerland
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Abstract
BACKGROUND Which factors predict recurrence in patients with Crohn's disease in the era of immunosuppressive medications is still under debate. OBJECTIVE The current study was conducted to assess long-term outcome after ileocolic resection for Crohn's disease and to define predictive factors for surgical relapse. DESIGN This is a retrospective study. SETTINGS The study was conducted in a tertiary referral center. PATIENTS A consecutive cohort of patients (n = 203) with Crohn's disease who underwent ileocolic resection between 1997 and 2006 were analyzed. The mean follow-up time was 8.4 (±2.4) years. MAIN OUTCOME MEASURES The cumulative probability for repeated intestinal resection for recurrent Crohn's disease was described by Kaplan-Meier curves. Predictors of surgical recurrence were analyzed by univariate tests. RESULTS One hundred five patients (51.7%) were exposed to azathioprine/6-mercaptopurine, and 28 patients (13.8%) were exposed to tumor necrosis factor-α blockers after operation. During the follow-up period, 32 patients (15.8%) were reoperated on for disease recurrence. At 5 and 10 years after index surgery, 95.5% and 81.3% of the patients had reoperation-free survival. Previous resections for Crohn's disease (HR, 2.981; 95% CI, 1.411-6.29; p = 0.003) and urgent indication for surgery (HR, 2.729; 95% CI, 1.047-7.116; p = 0.03) were significant risk factors for reoperation. In addition, patients with postoperative complications following ileocolonic resection were more likely to require reoperation (HR, 1.712; 95% CI, 041-2.817; p = 0.03). In a multiple Cox regression model, previous intestinal resection for Crohn's disease remained significant (p = 0.0114) with a HR of 2.654 (95% CI, 1.246-5.654). LIMITATIONS The limitation is the retrospective design of the study, with its potential selection bias. CONCLUSION In the present analysis, previous intestinal resection for Crohn's disease was found to be an independent risk factor for surgical recurrence. Consequently, shorter surveillance intervals in this group of patients should be considered.
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Ueno F, Matsui T, Matsumoto T, Matsuoka K, Watanabe M, Hibi T, On Behalf of the Guidelines Project Group of the Research Group of Intractable Inflammatory Bowel Disease subsidized by the Ministry of Health, Labour and Welfare of Japan and the Guidelines Committee of the Japanese Society of Gastroenterology. Evidence-based clinical practice guidelines for Crohn's disease, integrated with formal consensus of experts in Japan. J Gastroenterol 2013; 48:31-72. [PMID: 23090001 PMCID: PMC3541931 DOI: 10.1007/s00535-012-0673-1] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 08/16/2012] [Indexed: 02/04/2023]
Abstract
Crohn's disease is a disorder of unknown etiology and complicated pathogenesis. A substantial amount of evidence has accumulated recently and has been applied to clinical practice. The present guidelines were developed based on recent evidence and the formal consensus of experts relevant to this disease. Here we provide an overview of these guidelines, as follows. Target disease: Crohn's disease Users: Clinical practitioners in internal medicine, surgery, gastroenterology, and general practice Purpose: To provide appropriate clinical indicators to practitioners Scope of clinical indicators: Concept of Crohn's disease, epidemiology, classifications, diagnosis, treatment, follow up, and special situations Intervention: Diagnosis (interview, physical examination, clinical laboratory tests, imaging, and pathology) and treatment (lifestyle guidance, drug therapy, nutritional therapy, surgery, etc.) Outcome assessment: Attenuation of symptoms, induction and maintenance of remission, imaging findings, quality of life (QOL), prevention of complications and harm of therapy Methods for developing these guidelines: Described in the text Basis of recommendations: Integration of evidence level and consensus of experts Cost-benefit analysis: Not implemented Evaluation of effectiveness: Yet to be confirmed Status of guidelines: Updated version of the first Guidelines published in 2010 Publication sources: Printed publication available and electronic information in preparation Patient information: Not available Date of publication: October 2011 These guidelines were intended primarily to be used by practitioners in Japan, and the goal of these guidelines is to improve the outcomes of patients with Crohn's disease.
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Affiliation(s)
| | - Toshiyuki Matsui
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Takayuki Matsumoto
- Division of Lower Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Katsuyoshi Matsuoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinano-machi Shinjuku, Tokyo, 160-8582 Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshifumi Hibi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinano-machi Shinjuku, Tokyo, 160-8582 Japan
| | - On Behalf of the Guidelines Project Group of the Research Group of Intractable Inflammatory Bowel Disease subsidized by the Ministry of Health, Labour and Welfare of Japan and the Guidelines Committee of the Japanese Society of Gastroenterology
- Ofuna Chuo Hospital, Kanagawa, Japan
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
- Division of Lower Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinano-machi Shinjuku, Tokyo, 160-8582 Japan
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
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Lee KY, Yu CS, Lee KY, Cho YB, Park KJ, Choi GS, Yoon SN, Yoo H. Risk factors for repeat abdominal surgery in korean patients with Crohn's disease: a multi-center study of a korean inflammatory bowel disease study group. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2012; 28:188-94. [PMID: 22993704 PMCID: PMC3440487 DOI: 10.3393/jksc.2012.28.4.188] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2012] [Accepted: 08/03/2012] [Indexed: 12/14/2022]
Abstract
Purpose The purpose of this study was to assess the risk factors for repeated abdominal surgery in Crohn's disease (CD) patients after the first abdominal surgery. Prior studies have tried to identify the risk factors for postoperative recurrence in CD patients, but the results of the studies have been inconsistent. Furthermore, few data on the risk factors for repeated abdominal surgery are available. Methods Clinical data on CD patients who underwent abdominal surgery from January 2000 to December 2009 were collected from seventeen university hospitals and one colorectal clinic. Data from a total of 708 patients were analyzed to find the risk factors for repeated abdominal surgery in CD patients. The mean follow-up period was 72 months. Results The risk of repeated abdominal surgery was 3 times higher in young patients (below 16 years old) than in older patients (odds ratio [OR], 3.056; 95% confidence interval [CI], 1.021 to 9.150); P = 0.046). Stricturing behavior at diagnosis was also a risk factor for repeated abdominal surgery (OR, 2.438; 95% CI, 1.144 to 5.196; P = 0.021). Among operative indications, only intra-abdominal abscess was associated with repeated abdominal surgery (OR, 2.393; 95% CI, 1.098 to 5.216; P = 0.028). Concerning type of operation, an ileostomy might be a risk factor for repeated abdominal surgery (OR, 11.437; 95% CI, 1.451 to 90.124; P = 0.021). Emergency surgery (OR, 4.994; 95% CI, 2.123 to 11.745; P < 0.001) and delayed diagnosis after surgery (OR, 2.339; 95% CI, 1.147 to 4.771; P = 0.019) also increased the risk of repeated abdominal surgery. Conclusion Young age (below 16 years), stricturing behavior, intra-abdominal abscess, emergency surgery, and delayed diagnosis after surgery were identified as possible risk factors for repeated abdominal surgery in CD patients.
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Affiliation(s)
- Kil Yeon Lee
- Department of Surgery, Kyung Hee University School of Medicine, Seoul, Korea
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De Cruz P, Kamm MA, Prideaux L, Allen PB, Desmond PV. Postoperative recurrent luminal Crohn's disease: a systematic review. Inflamm Bowel Dis 2012; 18:758-77. [PMID: 21830279 DOI: 10.1002/ibd.21825] [Citation(s) in RCA: 145] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 06/15/2011] [Indexed: 12/20/2022]
Abstract
Despite improved immunosuppressive therapy, surgical resection is still often required for uncontrolled inflammatory disease and the stenosing and perforating complications of Crohn's disease. However, surgery is not curative. A majority of patients develop disease recurrence at or above the anastomosis. Subclinical endoscopically identifiable recurrence precedes the development of clinical symptoms; identification and treatment of early mucosal recurrence may therefore prevent clinical recurrence. Therapy to achieve mucosal healing should now be the focus of postoperative therapy. A number of clinical risk factors for the development of earlier postoperative recurrence have been identified, and reasonable evidence is now available regarding the efficacy of drug therapies in preventing recurrence. This evidence now needs to be incorporated into prospective treatment strategies.
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Affiliation(s)
- Peter De Cruz
- Department of Gastroenterology and Medicine, St Vincent's Hospital, Melbourne, Australia
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18
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Buisson A, Chevaux JB, Allen PB, Bommelaer G, Peyrin-Biroulet L. Review article: the natural history of postoperative Crohn's disease recurrence. Aliment Pharmacol Ther 2012; 35:625-33. [PMID: 22313322 DOI: 10.1111/j.1365-2036.2012.05002.x] [Citation(s) in RCA: 267] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 10/16/2011] [Accepted: 01/08/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgical resection of the diseased bowel in Crohn's disease is unfortunately not curative, and postoperative recurrence remains a problem in these patients. AIM To review the rates of and risk factors for clinical and endoscopic recurrence in population-based studies, referral centres and randomised controlled trials. METHODS We searched MEDLINE (source PUBMED, 1966 to September, 2011). RESULTS In randomised controlled trials, clinical recurrence in the first year after surgery occurred in 10-38% of patients, whereas endoscopic recurrence in the first year was reported in 35-85% of patients. In population-based studies, approximately half of patients experienced clinical recurrence at 10 years. In referral centres, 48-93% of the patients had endoscopic lesions (Rutgeerts' score ≥1) in the neoterminal ileum within 1 year after surgery, whereas 20-37% had symptoms suggestive of clinical recurrence. Three years after surgery, the endoscopic postoperative recurrence rate increased to 85-100%, and symptomatic recurrence occurred in 34-86% of patients. Smoking is the strongest risk factor for postoperative recurrence, increasing by twofold, the risk of clinical recurrence. Prior intestinal resection, penetrating behaviour, perianal disease and extensive bowel disease (>50 cm) are established risk factors for postoperative recurrence. Risk factors for postoperative recurrence remain poorly defined in population-based cohorts. CONCLUSION Endoscopic and clinical postoperative recurrence remains common in patients with Crohn's disease, and the identification of risk factors may allow targeted strategies to reduce this recurrence rate.
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Affiliation(s)
- A Buisson
- Department of Hepato-Gastroenterology, University Hospital Estaing of Clermont-Ferrand, Auvergne University, Clermont-Ferrand, France
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Watanabe T, Sasaki I, Sugita A, Fukushima K, Futami K, Hibi T, Watanabe M. Interval of less than 5 years between the first and second operation is a risk factor for a third operation for Crohn's disease. Inflamm Bowel Dis 2012; 18:17-24. [PMID: 21381153 DOI: 10.1002/ibd.21671] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 01/10/2011] [Indexed: 12/31/2022]
Abstract
BACKGROUND Previous studies have shown various risk factors for the initial and/or the second operation for Crohn's disease (CD). However, limited data are available with regard to the risk factors for a third operation. We aimed to clarify the risk factors for a third operation for CD. METHODS A total of 200 CD patients who underwent a second intestinal surgery at 13 institutions were examined. We performed univariate and multivariate analyses to examine the influence of independent variables on the cumulative rate of needing a third operation. RESULTS A total of 95 patients underwent a third operation. The overall 5-year and 10-year cumulative rates for the third operation were 42.2% and 71.0%, respectively. In univariate analysis, the interval between the initial and the second operation (P = 0.0069), postoperative administration of infliximab (P = 0.0030), and the anatomical site of the disease (P = 0.0132) were significant risk factors for the third operation. In multivariate analysis, the interval between the initial and the second operation (P = 0.0287) and postoperative administration of infliximab (P = 0.0297) remained significant risk factors for the third operation. The cumulative 5-year third operation rate was significantly higher in patients with an interval of less than 5 years between the first and second operations than for those with an interval of 5 years or more (47.8% versus 35.2%, P = 0.0232). CONCLUSIONS An interval of less than 5 years between the first and the second operations is a significant risk factor for a third operation in patients with CD.
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Affiliation(s)
- Toshiaki Watanabe
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan.
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Abstract
PURPOSE This study used meta-analytical techniques to compare the recurrence of granulomatous vs nongranulomatous Crohn disease. METHODS Comparative studies published between 1954 and 2007 of granulomatous vs nongranulomatous Crohn disease were included. Using a random effects model, end points evaluated were the number of recurrences and reoperations, and the time to recurrence and reoperation, of granulomatous vs nongranulomatous Crohn disease. Heterogeneity was assessed and sensitivity analysis was performed to account for bias in patient selection. RESULTS Twenty-one studies (14 nonrandomized retrospective, 7 nonrandomized prospective) reported on 2236 patients with Crohn disease, of whom 1050 (47.0%) had granulomas (granulomatous group) and 1186 (53.0%) had no granulomas (nongranulomatous group). The number of recurrences and reoperations was found to be significantly higher in the granulomatous group compared to the nongranulomatous group (odds ratio 1.37, P = .04; odds ratio 2.38, P < .001; respectively), with significant heterogeneity between studies (P = .06; P < .001; respectively). The time to recurrence and reoperation was significantly shorter in the granulomatous group compared with the nongranulomatous group (hazard ratio 1.63, P = .001; hazard ratio 1.62, P = .002; respectively), with no significant heterogeneity between studies. The number of recurrences and reoperations remained significantly higher in the granulomatous group compared to the nongranulomatous group during sensitivity analysis of higher-quality studies, more recent studies, and studies with a larger group of patients. CONCLUSIONS Granulomatous Crohn disease appears to be associated with a higher number of recurrences and reoperations and a shorter time to recurrence and reoperation compared to nongranulomatous Crohn disease. Because of significant heterogeneity between studies, further studies should be undertaken to confirm these findings.
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Pascua M, Su C, Lewis JD, Brensinger C, Lichtenstein GR. Meta-analysis: factors predicting post-operative recurrence with placebo therapy in patients with Crohn's disease. Aliment Pharmacol Ther 2008; 28:545-56. [PMID: 18565159 DOI: 10.1111/j.1365-2036.2008.03774.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The use of placebo in randomized clinical trials (PC-RCTs) is often required to evaluate drug efficacy in maintenance of Crohn's disease (CD). AIM To determine pooled estimates of placebo rates of maintaining clinical remission and endoscopic recurrence following surgery for CD and identify factors that influenced placebo outcomes. METHODS We performed a systematic review and meta-analysis of PC-RCTs evaluating post-operative maintenance therapies for CD identified from MEDLINE from 1966 to 2005. RESULTS Twelve studies met our inclusion criteria. The pooled placebo rate of maintaining clinical remission was 56% (95% CI 47-64%; range 34-89%) during a median follow-up of 52 weeks (range 12-156 weeks), but significant heterogeneity existed among the studies (P < 0.001). Prior steroid therapy was the only factor found to be associated with maintaining remission (P = 0.04). The pooled placebo endoscopic recurrence rate was 58% (95% CI 51-65%; range 36-80%) during a median follow-up of 52 weeks (range 12-156 weeks), with significant heterogeneity noted (P = 0.0003). Prior surgery, concomitant small bowel and colonic disease, fistulizing phenotype, or prior immunomodulator therapy influenced endoscopic recurrence (P < 0.05). CONCLUSION Placebo rates in PC-RCTs evaluating post-operative clinical and endoscopic recurrence demonstrate significant variability, which is influenced by specific study characteristics.
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Affiliation(s)
- M Pascua
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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Simillis C, Yamamoto T, Reese GE, Umegae S, Matsumoto K, Darzi AW, Tekkis PP. A meta-analysis comparing incidence of recurrence and indication for reoperation after surgery for perforating versus nonperforating Crohn's disease. Am J Gastroenterol 2008; 103:196-205. [PMID: 17900320 DOI: 10.1111/j.1572-0241.2007.01548.x] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study used meta-analytical techniques to compare the incidence of recurrence and the indication for reoperation in patients with Crohn's disease (CD) who underwent their first operation, due to perforating disease versus patients who underwent their first operation due to nonperforating disease. METHODS Comparative studies published between 1988 and 2005 of perforating versus nonperforating CD were included. Using a random effects model, end points evaluated were recurrence of CD given as reoperation, and the indication for reoperation, i.e., perforating or nonperforating. Heterogeneity (HG) was assessed and a sensitivity analysis was performed to account for bias in patient selection. RESULTS Thirteen studies (12 nonrandomized retrospective, 1 nonrandomized prospective) reported on 3,044 patients, of which 1,337 (43.9%) had perforating indications (P group) and 1,707 (56.1%) had nonperforating indications (NP group) for surgery. The recurrence was found to be significantly higher in the P group compared to the NP group (HR 1.50, P= 0.002), with significant HG among studies (P < 0.001). The recurrence remained significantly higher in the P group compared with the NP group during sensitivity analysis of high-quality studies (HR 1.47, P= 0.005) and more recent studies (HR 1.51, P= 0.05), but still demonstrating significant HG (P= 0.08 and P < 0.001, respectively). At reoperation, concordance was found in the disease type of those patients re-presenting with perforating disease (OR 5.93, P < 0.001, without significant HG among studies P= 0.15) and those with nonperforating disease (OR 5.73, P < 0.001, with significant HG among studies P < 0.001). Concordance in disease type remained when considering only high-quality studies (P: OR 7.48, P < 0.001; NP: OR 7.48, P < 0.001) and more recent studies (P: OR 5.95, P < 0.001; NP: OR 5.95, P < 0.001), both not associated with HG among studies (P= 0.47 and P= 0.60, respectively). CONCLUSIONS The indication for reoperation in CD tends to be the same as the primary operation, i.e., perforating disease tends to re-present as perforating disease, and nonperforating as nonperforating. Also, perforating CD appears to be associated with a higher recurrence rate compared with nonperforating CD. However, because of significant HG among studies, further studies should be undertaken to confirm this finding.
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Affiliation(s)
- Constantinos Simillis
- Department of Surgical Oncology and Technology, Imperial College London, London, U.K
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23
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Hong DH, Yu CS, Kim DD, Jung SH, Choi PH, Park IJ, Kim HC, Kim JC. Postoperative Complications and Recurrence in Patients with Crohn's Disease. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2008. [DOI: 10.3393/jksc.2008.24.1.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Dong Hyun Hong
- Colorectal Clinic, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chang Sik Yu
- Colorectal Clinic, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dae Dong Kim
- Colorectal Clinic, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Hun Jung
- Colorectal Clinic, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Pyong Hwa Choi
- Colorectal Clinic, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - In Ja Park
- Colorectal Clinic, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hee Cheol Kim
- Colorectal Clinic, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin Cheon Kim
- Colorectal Clinic, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Simillis C, Purkayastha S, Yamamoto T, Strong SA, Darzi AW, Tekkis PP. A meta-analysis comparing conventional end-to-end anastomosis vs. other anastomotic configurations after resection in Crohn's disease. Dis Colon Rectum 2007; 50:1674-87. [PMID: 17682822 DOI: 10.1007/s10350-007-9011-8] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study compared outcomes between end-to-end anastomosis and other anastomotic configurations after intestinal resection for patients with Crohn's disease by using meta-analytical techniques. METHODS Comparative studies published between 1992 and 2005 of end-to-end anastomosis vs. other anastomotic configurations were included. Using a random effects model, end points evaluated were short-term complications and perianastomotic recurrence of Crohn's disease. Heterogeneity was assessed and sensitivity analysis was performed to account for bias in patient selection. RESULTS Eight studies (2 prospective, randomized, controlled trials; 1 nonrandomized, prospective; 5 nonrandomized, retrospective studies) reported on 661 patients who underwent 712 anastomoses, of which 383 (53.8 percent) were sutured end-to-end anastomosis and 329 (46.2 percent) were other anastomotic configurations (259 stapled side-to-side, 59 end-to-side or side-to-end, 11 stapled circular end-to-end). Anastomotic leak rate was significantly reduced in the other anastomotic configurations group (odds ratio (OR), 4.37; P = 0.02) and remained significantly lower in studies comparing only side-to-side anastomosis vs. end-to-end anastomosis (OR, 4.37; P = 0.02) and studies including only ileocolonic anastomosis (OR, 3.8; P = 0.05). Overall postoperative complications (OR, 2.64; P < 0.001), complications other than anastomotic leak (OR, 1.89; P = 0.04), and postoperative hospital stay (weighted mean difference, 2.81; P = 0.007) were significantly reduced in the side-to-side anastomosis group when considering studies comparing only side-to-side anastomosis vs. end-to-end anastomosis. There was no significant difference between the groups in perianastomotic recurrence and reoperation needed because of perianastomotic recurrence. CONCLUSIONS End-to-end anastomosis after resection for Crohn's disease may be associated with increased anastomotic leak rates. Side-to-side anastomosis may lead to fewer anastomotic leaks and overall postoperative complications, a shorter hospital stay, and a perianastomotic recurrence rate comparable to end-to-end anastomosis. Further randomized, controlled trials should be performed for confirmation.
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Affiliation(s)
- Constantinos Simillis
- Department of Biosurgery and Surgical Technology, Imperial College London, London, United Kingdom
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Welsch T, Hinz U, Löffler T, Muth G, Herfarth C, Schmidt J, Kienle P. Early re-laparotomy for post-operative complications is a significant risk factor for recurrence after ileocaecal resection for Crohn's disease. Int J Colorectal Dis 2007; 22:1043-9. [PMID: 17390141 DOI: 10.1007/s00384-007-0309-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is evidence suggesting that stenosing and fistulising Crohn's diseases reflect specific entities. The aim of this study was to compare these two clinical presentations with regards to anastomotic recurrence after ileocaecal resection and identify other relevant risk factors. MATERIALS AND METHODS One hundred consecutive patients undergoing isolated ileocaecal resection for Crohn's disease were included in this follow-up study. A recurrence was either defined endoscopically, on the basis of radiological examinations or on the basis of a re-operation. In addition, patients had to complain of clinical symptoms. Recurrence-free intervals were calculated by the Kaplan-Meier method. Univariate and multivariate analysis including previously identified risk factors for recurrence were performed. RESULTS Of the 100 patients extracted from the database, 8 patients were lost to follow-up or refused participation. There was no mortality in this patient group, the morbidity was 16.3%. The recurrence rates after 5 and 9 years were 28.7% and 56.4%, respectively. Univariate analysis revealed re-laparotomy within the same hospital stay and length of resected specimen as significant factors for anastomotic recurrence. Both these factors were confirmed on multivariate analysis. But when analysing the observation period in detail, specimen length was not any more a significant factor in the later time period (1996-2000) compared to the earlier time period (1991-1995). The clinical presentation (fistulising vs stenosing) showed no significant influence on the recurrence rates. CONCLUSIONS Patients with stenosing and fistulising Crohn's disease of the ileocaecal region have no difference in recurrence rates after resection. Re-laparotomy in the same hospital stay was an independent predictor of recurrence.
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Affiliation(s)
- Thilo Welsch
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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Steele SR. Operative management of Crohn's disease of the colon including anorectal disease. Surg Clin North Am 2007; 87:611-31. [PMID: 17560415 DOI: 10.1016/j.suc.2007.03.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Evaluation and management of the patient who has Crohn's disease of the colon, rectum, and anus is challenging for even the most experienced provider. Because of its broad spectrum of presentation, recurrent nature, and potential for high morbidity, the surgeon needs to not only treat the acute situation but also keep in mind the potential long-term ramifications. Although there are exciting new medications and treatment modalities yielding promising results, surgery continues to remain at the forefront for the care of these patients. This article reviews various surgical options for the patient who has Crohn's disease of the colon, rectum, and perianal region with emphasis on symptomatic resolution and optimization of function.
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Affiliation(s)
- Scott R Steele
- Colon & Rectal Surgery, Department of Surgery, Madigan Army Medical Center, Fort Lewis, WA 98431, USA.
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Radford-Smith G, Pandeya N. Associations between NOD2/CARD15 genotype and phenotype in Crohn’s disease-Are we there yet? World J Gastroenterol 2006; 12:7097-103. [PMID: 17131470 PMCID: PMC4087769 DOI: 10.3748/wjg.v12.i44.7097] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
There have been multiple NOD2/CARD15 genotype-phenotype analyses undertaken in patients with Crohn's disease since the gene’s discovery in 2001. This review focuses on the major published series based upon their size and on the presence of specific clinical and genetic information provided in the published material from 2001 to 2005. Twelve studies provided raw data to carry out comparisons of disease location while ten studies included analysis of NOD2/CARD15 genotypes. NOD2/CARD15 variant frequency in ileal disease did not differ significantly among studies, whereas a comparison of disease location demonstrated highly significant differences among studies. Meta-analysis confirmed significant associations between NOD2/CARD15 variants and both ileal and ileocolonic disease locations, and with both stricturing and penetrating forms of disease behavior. This review underlines the significant phenotypic differences that exist among populations, including similar ethnic groups, and has demonstrated the need for further studies of patients with long-term “inflammatory” Crohn’s disease.
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Affiliation(s)
- Graham Radford-Smith
- IBD Unit, Department of Gastroenterology, Royal Brisbane and Womens Hospital, Brisbane, Queensland 4029, Australia.
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Landsend E, Johnson E, Johannessen HO, Carlsen E. Long-term outcome after intestinal resection for Crohn's disease. Scand J Gastroenterol 2006; 41:1204-8. [PMID: 16990206 DOI: 10.1080/00365520600731018] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess the need for intestinal repeat resection for recurrence of Crohn's disease in patients observed for more than 20 years after the first resection. MATERIAL AND METHODS Data were gathered retrospectively from the medical records of 53 (28 F) consecutive patients with Crohn's disease from May 1954 to December 2002. Median age at first intestinal resection was 24.5 (range 13-65) years, and median observation time thereafter was 26.5 (20.1-48.6) years. Disease location and behaviour were defined according to the Vienna classification. RESULTS The 53 patients had an average 2.7 and a median 2 intestinal resections. Out of 144 intestinal resections (77.1%) 111 were performed during the first three operations; no alterations in distribution of ileal, ileocolic and colic resections were found. From the first to the third operation there was an increase in penetrating disease from 15% to 39% (p=0.046) concomitant with a decrease in stricturing disease from 72% to 44% (p=0.048) of the patients. There was also a corresponding decrease in ileocolic disease from 45% to 5% (p=0.003) and a tendency towards an increase in ileal disease from 38% to 67%. One patient died (1.8%) from rectosigmoid perforation after the third resectional operation. Six patients needed reoperation (11.3%) for ileus, anastomotic bleeding, rectosigmoidal perforation and abdominal pain. Thirty-four patients (64.2%) needed intestinal repeat resection (median 8.3 years) during 25.3 years after the first repeat resection. CONCLUSIONS This study indicates a diminution of Crohn's disease activity with time, as demonstrated by no need for intestinal repeat resection more than 25 years after the first resection.
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Affiliation(s)
- Erlend Landsend
- Department of Gastroenterological Surgery, Ullevål University Hospital, Oslo, Norway
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Fichera A, Lovadina S, Rubin M, Cimino F, Hurst RD, Michelassi F. Patterns and operative treatment of recurrent Crohn's disease: a prospective longitudinal study. Surgery 2006; 140:649-54. [PMID: 17011913 DOI: 10.1016/j.surg.2006.07.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2006] [Accepted: 07/13/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND It is believed commonly that Crohn's recurrences always occur at the site of a previous intestinal anastomosis; yet this concept is probably inaccurate and not mindful of the panintestinal nature of the disease. MATERIALS AND METHODS Between October, 1984 and March, 2003, we carried out 1,132 procedures (464 for primary and 668 for recurrent disease) on 981 consecutive patients. Patients in whom we carried out both the original procedure as well as the procedure for recurrent disease constitute this study population. Operative procedures for perineal complications were excluded from this analysis. Data were accrued prospectively. RESULTS Seventy-eight patients met the study inclusion criteria. They had a total of 149 sites of disease (duodenum, n = 3; jejunum/ileum, n = 53; terminal ileum/neo terminal ileum, n = 67; colon and rectum, n = 26). One hundred thirty-four sites required operative intervention (85 resections and 49 strictureplasties) and 15 did not. Crohn's disease recurred in 79 sites after a mean of 48.4 months (range, 1-161 months, median, 41 months). Site of operative intervention and operative technique influenced patterns of recurrence: when an anastomosis or strictureplasty was constructed with small bowel, the majority of recurrences were limited to the anastomotic line (17/29, 59%); when it was constructed with small bowel and colon, the majority of recurrences extended to the proximal limb (29/35, 83%). The difference in recurrence pattern is significant (P < .01). In addition, fewer recurrences occurred at strictureplasty than resection sites (22/49, 45%, vs 57/85, 70%, respectively, P < .05). At the time of the second procedure, 40 additional recurrences were identified distant from the original operative site. Four of these represented progression of disease at the 15 sites that did not originally need operative intervention. Of 119 total recurrences, 115 required 73 resections, 40 strictureplasties, and 2 other procedures. CONCLUSIONS The site of the original operative intervention is the most common site for recurrence, although as many as one-third of recurrences occur separate from it. Pattern of recurrence is influenced by site of the operative intervention (anastomotic for small bowel, proximal limb for ileocolonic) and by operative technique (fewer recurrences occurred at strictureplasty than resection sites). Disease progression occurred in 25% of the sites not addressed operatively at the original procedure. The operative strategy applied to Crohn's complications in different intestinal sites was similar for primary and recurrent disease.
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Ferrante M, de Hertogh G, Hlavaty T, D'Haens G, Penninckx F, D'Hoore A, Vermeire S, Rutgeerts P, Geboes K, van Assche G. The value of myenteric plexitis to predict early postoperative Crohn's disease recurrence. Gastroenterology 2006; 130:1595-606. [PMID: 16697723 DOI: 10.1053/j.gastro.2006.02.025] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2005] [Accepted: 02/01/2006] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Early ileocolonoscopy allows detection of recurrence after surgically induced remission of Crohn's disease (CD). Unequivocal histologic markers predicting recurrence have not been identified. We assessed the predictive value of neural lesions for early endoscopic CD recurrence and long-term reintervention risk. METHODS Ileocolonic resection specimens from 59 patients with CD and 21 control patients were histologically scored for typical inflammatory bowel disease lesions, neural hypertrophy, and presence and severity of inflamed ganglia and nerve bundles. Endoscopic recurrence was determined at 3 months in all patients and at 1 year in 32 patients as part of 2 prospective clinical trials. RESULTS Myenteric plexitis of the proximal resection margin was present in 32 patients with CD (54%) in absence of surrounding inflammation. Patients with this feature had a higher endoscopic recurrence (Rutgeerts score >/=2) at 3 months (75% vs 41%; odds ratio, 4.36; 95% confidence interval, 1.44-13.23; P = .008) and at 1 year (93% vs 59%; odds ratio, 9.80; 95% confidence interval, 1.04-92.70; P = .041) and had a trend toward an earlier reintervention (mean, 7.00 vs 5.30 years; P = .174). The severity of myenteric plexitis in the proximal resection margin correlated with the severity of endoscopic recurrence at 3 months (r = 0.334, P = .010) and 1 year (r = 0.560, P = .001). Myenteric plexitis was the only consistent predictor of endoscopic recurrence. CONCLUSIONS The presence of myenteric plexitis in proximal margins of ileocolonic resection specimens is predictive of early endoscopic CD recurrence.
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Affiliation(s)
- Marc Ferrante
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium
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Abstract
More than three quarters of patients with Crohn's disease (CD) will require surgery. After resection, disease recurs postoperatively with a median time to second resection of about 10 years. Despite its importance, the postoperative period remains one of the most poorly understood clinical settings in the field. Postoperatively, CD may exhibit unique pathophysiologic features, but the current state of knowledge does not allow for identification of patients at risk for relapse, and leaves clinicians without guidance on optimal maintenance treatment. Therapies used as maintenance for CD in other settings may have different efficacies when used after surgery, and clinical research in patients requiring surgery is limited by the subset of patients available for study. Despite the many limitations in current knowledge of postoperative CD, it is an exciting field because new developments have improved patient care, and ongoing research has the potential for further gains.
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Affiliation(s)
- Robert M Penner
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada
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Abstract
Although in Crohn’s disease post-operative recurrence is common, the determinants of disease recurrence remain speculative. The aim of this study was to examine factors affecting post-operative recurrence of Crohn’s disease. A Medline-based literature review was carried out. The following factors were investigated: age at onset of disease, sex, family history of Crohn’s disease, smoking, duration of Crohn’s disease before surgery, prophylactic medical treatment (corticosteroids, 5-amino salicylic acid [5-ASA] and immunosuppressants), anatomical site of involvement, indication for surgery (perforating or non-perforating disease), length of resected bowel, anast-omotic technique, presence of granuloma in the specimen, involvement of disease at the resection margin, blood transfusions and post-operative complications. Smoking significantly increases the risk of recurrence (risk is approximately twice as high), especially in women and heavy smokers. Quitting smoking reduces the post-operative recurrence rate. A number of studies have shown a higher risk when the duration of the disease before surgery was short. There were, however, different definitions of ‘short’ among the studies. Prophylactic cortic-osteroids therapy is not effective in reducing the post-operative recurrence. A number of randomized controlled trials offered evidence of the efficacy of 5-ASA (mesalazine) in reducing post-operative recurrence. Recently, the thera-peutic efficacy of immunosuppressive drugs (azathioprine and 6-mercaptopurine) in the prevention of post-operative recurrence has been investigated and several studies have reported that these drugs might help prevent the recurrence. Further clinical trials would be necessary to evaluate the prophylactic efficacy of immunosuppressants. Several studies showed a higher recurrence rate in patients with perforating disease than in those with non-perforating disease. However, evidence for differing recurrence rates in perforating and non-perforating diseases is inconclusive. A number of retrospective studies reported that a stapled functional end-to-end anastomosis was associated with a lower recurrence rate compared with other types of anastomosis. However, prospective randomized studies would be necessary to draw a definite conclusion. Many studies found no difference in the recurrence rates between patients with radical resection and non-radical resection. Therefore, minimal surgery including strictureplasty has been justified in the management of Crohn’s disease. In this review, the following factors do not seem to be predictive of post-operative recurrence: age at onset of disease, sex, family history of Crohn’s disease, anatomical site of disease, length of resected bowel, presence of granuloma in the specimen, blood transfusions and post-operative complications. The most significant factor affecting post-operative recurrence of Crohn’s disease is smoking. Smoking significantly increases the risk of recurrence. A short disease duration before surgery seems, albeit to a very minor degree, to be associated with a higher recurrence rate. 5-ASA has been shown with some degree of confidence to lead to a lower recurrence rate. The prophylactic efficacy of immunosuppressive drugs should be assessed in future. A wider anastomotic technique after resection may reduce the post-operative recurrence rate, though this should be investigated with prospective randomized controlled trials.
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Affiliation(s)
- Takayuki Yamamoto
- Inflammatory Bowel Disease Center and Department of Surgery, Yokkaichi Social Insurance Hospital, 10-8 Hazuyamacho, Yokkaichi, Mie 510-0016, Japan.
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Wolters FL, Russel MGVM, Stockbrügger RW. Systematic review: has disease outcome in Crohn's disease changed during the last four decades? Aliment Pharmacol Ther 2004; 20:483-96. [PMID: 15339320 DOI: 10.1111/j.1365-2036.2004.02123.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Disease outcome in Crohn's disease might have changed during the last four decades. Disease outcome measurement in Crohn's disease has methodological difficulties because of patient selection and lack of proper definition of diagnostic and outcome measurement criteria. AIM To assess possible changes in disease outcome in Crohn's disease during the last four decades. METHODS A systematic literature search was performed using the MEDLINE search engine and major international conference libraries. Articles and abstracts were selected according to stringent inclusion criteria. RESULTS Forty articles and nine abstracts complied with the inclusion criteria. Seven studies with a median follow-up time between 11.1 and 17 years showed standard mortality ratios in Crohn's disease ranging between 2.16 and 0.72 with a tendency of decline during the last four decades. One study with 11.4 years mean follow-up time showed a statistically significant increased relative risk for colorectal cancer that was not confirmed by three others. Sixteen publications applied in the disease recurrence category. Probability of first resective surgery ranged between 38 and 96% during the first 15 years after diagnosis. The overall recurrence and surgical recurrence rates after first resective surgery ranged between 50 and 60, and 28 and 45% respectively during the following 15 years without an apparent time trend. CONCLUSION This structured literature review provides no hard evidence for change in disease outcome in Crohn's disease during the last four decades.
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Affiliation(s)
- F L Wolters
- Department of Gastroenterology and Hepatology, University Hospital Maastricht, Maastricht, The Netherlands.
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Sampietro GM, Cristaldi M, Maconi G, Parente F, Sartani A, Ardizzone S, Danelli P, Bianchi Porro G, Taschieri AM. A prospective, longitudinal study of nonconventional strictureplasty in Crohn’s disease1 1No competing interests declared. J Am Coll Surg 2004; 199:8-20; discussion 20-2. [PMID: 15217622 DOI: 10.1016/j.jamcollsurg.2004.01.039] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2003] [Revised: 01/27/2004] [Accepted: 01/28/2004] [Indexed: 12/30/2022]
Abstract
BACKGROUND Bowel-sparing techniques have been proposed to avoid extended or repeated resections in patients with Crohn'rsquo;s disease (CD), but without precise indications, prospective evaluation, and with a technically limited repertoire. STUDY DESIGN A prospective longitudinal study of new nonconventional strictureplasties (NCSP) in order to evaluate the safety, type and site of recurrence, and longterm clinical and surgical efficacy. RESULTS Between January 1993 and December 2002, 102 among 305 consecutive patients underwent at least one NCSP for complicated CD. Patients were treated following precise indications and then included in a prospective database with scheduled followup. Factors claimed to influence postoperative and longterm outcomes and type and site of recurrence were analyzed. We performed 48 ileoileal side-to-side isoperistaltic strictureplasty (SP), 41 widening ileocolic SP, 32 ileocolic side-to-side isoperistaltic SP, associated with Heineke-Mikulicz SP (in 80 procedures) or with minimal bowel resections or both (in 47 procedures). Postoperative mortality was nil; complication rate was 5.7%. Ten years clinical and surgical recurrence rates were 43% and 27%, respectively. Recurrence rate on an NCSP site was 0.8%. No specific factor was identified as related to postoperative or longterm outcomes. CONCLUSIONS Perioperative and longterm results of NCSP are comparable to or even better than both conservative and resective surgery as reported in the literature, with a low recurrence rate on the NCSP site. Considering the unpredictability of the clinical course of CD and the lifetime need for surgical procedures, NCSP, together with minimal resection and classic SP repertoire, should be considered first-line treatment in complicated CD.
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Affiliation(s)
- Gianluca M Sampietro
- Department of Surgery, II Division of General Surgery, Università degli Studi di Milano, Ospedale Luigi Sacco, Milan, Italy
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Yamamoto T, Umegae S, Kitagawa T, Matsumoto K. Mucosal cytokine production during remission after resection for Crohn's disease and its relationship to future relapse. Aliment Pharmacol Ther 2004; 19:671-8. [PMID: 15023169 DOI: 10.1111/j.1365-2036.2004.01899.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM To examine whether mucosal cytokine production during remission after resection for Crohn's disease is a predictor of future relapse. METHODS Thirty-six patients who remained in remission after resection for terminal ileal or ileo-caecal Crohn's disease were included. At enrollment, blood and mucosal (ileal and rectal biopsies) samples were collected. All patients were followed up regularly for 1 year after enrollment and the disease activity was assessed according to the Crohn's disease activity index. RESULTS Twenty patients remained in remission and 16 patients relapsed during the 1-year follow-up. Interleukin-1 beta, interleukin-6 and tumour necrosis factor-alpha levels in the ileal mucosa were significantly higher in relapsed patients than in patients in remission. These cytokine levels in the rectal mucosa were not associated with relapse. Conventional blood markers and plasma cytokine levels did not correlate with relapse. Amongst the clinical parameters, a younger age, short disease duration before operation and fistulating disease were risk factors for relapse. In multivariate analysis, only the ileal interleukin-6 level was an independent significant predictor for relapse. CONCLUSIONS The interleukin-6 level in the ileal mucosa during remission after resection for ileal or ileo-caecal Crohn's disease is an independent significant predictor for future relapse.
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Affiliation(s)
- T Yamamoto
- Inflammatory Bowel Disease Centre and Department of Surgery, Yokkaichi Social Insurance Hospital, Yokkaichi, Mie, Japan.
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Abstract
The clinical relapse rate after surgery for Crohn's disease in prospective studies is about 40% at 2 years in people who receive no postoperative prophylaxis. Thiopurines (azathioprine and 6-mercaptopurine) are likely to be the most effective pharmacotherapy for preventing postoperative relapse: about four patients need to be treated for 2 years to prevent one clinical relapse. The factors that help to identify patients at highest risk of relapse are discussed, along with the reasons for the choice of thiopurine, dose and duration of therapy. Other measures to reduce the relapse rate are addressed.
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Affiliation(s)
- S Travis
- Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK.
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Affiliation(s)
- B G Wolff
- Department of Surgery, Mayo Clinic and Mayo Foundation, 200 First Street SW, Rochester, Minnesota 55905, USA
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38
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Abstract
PURPOSE Previous studies on recurrence and reoperation after colectomy in Crohn's colitis have been based on heterogeneous groups of patients, and divergent findings may be explained by referral biases and small numbers of patients. The aim of this study was to account for recurrence rates, present risk factors for recurrence after primary colectomy, and account for the ultimate risk of having a stoma after colectomy with ileorectal anastomosis in patients with Crohn's colitis. METHODS Data on the primary resection, postoperative recurrence, influence of concomitant risk factors, frequency of stoma operations and proctectomy were evaluated retrospectively using multivariate analysis in a population-based cohort of 833 patients with Crohn's colitis. RESULTS The cumulative 10-year risk of a symptomatic recurrence was 58 percent (95 percent confidence interval, 53-63 percent) and 47 percent (95 percent confidence interval, 42-52 percent), respectively, after colectomy with ileorectal anastomosis and segmental colonic resection. In colectomy with ileostomy, lower rates were found with respectively 24 percent (95 percent confidence interval, 18-30 percent) and 37 percent (95 percent confidence interval, 32-43 percent) after subtotal colectomy and proctocolectomy with ileostomy. The multivariate analysis showed that perianal disease, ileorectal anastomosis, and segmental resection were independent risk factors for postoperative recurrence. In 76 percent of patients with ileorectal anastomosis, a stoma-free function could be retained during a median follow-up of 12.5 years. CONCLUSION Colectomy with ileorectal anastomosis or segmental resection is a feasible option in the surgical treatment of Crohn's colitis, although anastomoses, in addition to perianal disease, carry an increased risk of recurrent disease.
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Affiliation(s)
- O Bernell
- Departments of Surgery and Gastroenterology, Huddinge University Hospital, Sweden
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Girodengo L, Barthet M, Desjeux A, Berdah S, Berthezene P, Bellon P, Salducci J, Grimaud JC. [Risk factors for Crohn's disease relapse after treatment of intestinal stenosis]. ANNALES DE CHIRURGIE 2001; 126:296-301. [PMID: 11413807 DOI: 10.1016/s0003-3944(01)00519-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Postoperative recurrences of Crohn's disease (CD) has been widely investigated in previous studies. Nevertheless, the risk factors for CD recurrence in patients presenting with intestinal stenosis are not clearly identified. PATIENTS AND METHOD Thirty consecutive patients out of a cohort of 134 patients with CD presented with an intestinal stenosis diagnosed between 1995 and 1999. Epidemiological, clinical, and therapeutic data were carefully recorded. A univariate analysis followed by stepwise descending discriminant analysis was performed. RESULTS Sixteen patients (53%) underwent surgery, six received steroid therapy, eight were given antibiotics, and seven took immunosuppressive drugs. The mean follow-up after medical or surgical management was 2.8 years. Thirteen patients (43%) had CD relapse during the follow-up. Considering the univariate analysis, the existence of a previous appendectomy and the persistence of tobacco consumption were significantly associated with the risk of CD relapse during the follow-up. The stepwise descending discriminant analysis identified three independant factors: tobacco consumption (p = 0.007), previous appendicectomy (p = 0.04) and duration of the follow-up (p = 0.02). CONCLUSION The CD relapse after the management of small bowel stenosis occurred in 43% of the patients within a mean follow-up of 2.8 years. The significant factors associated with the risk of CD relapse were tobacco consumption, previous appendectomy and duration of the follow-up.
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Affiliation(s)
- L Girodengo
- Service de gastroentérologie, hôpital Nord, chemin des Bourrely, 13915 Marseille, France
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Maconi G, Sampietro GM, Cristaldi M, Danelli PG, Russo A, Bianchi Porro G, Taschieri AM. Preoperative characteristics and postoperative behavior of bowel wall on risk of recurrence after conservative surgery in Crohn's disease: a prospective study. Ann Surg 2001; 233:345-52. [PMID: 11224621 PMCID: PMC1421249 DOI: 10.1097/00000658-200103000-00007] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate in patients with Crohn's disease, using transabdominal ultrasound, the morphologic characteristics of the diseased bowel wall before and after conservative surgery and to assess whether these characteristics and their behavior in the postoperative follow-up are useful and reliable prognostic factors of clinical and surgical recurrence. SUMMARY BACKGROUND DATA Ultrasound is effective for evaluating the thickness of bowel wall, the most typical and constant finding of Crohn's disease. No data are currently available concerning the behavior of the diseased intestinal wall after conservative surgery and whether the preoperative characteristics of bowel wall or its behavior after conservative surgery may predict recurrence. METHODS In 85 consecutive patients treated with strictureplasty and miniresections for Crohn's disease, clinical and ultrasonographic evaluations were performed before and 6 months after surgery. Assessed before surgery were the maximum bowel wall thickness, the length of bowel wall thickening, the bowel wall echo pattern (homogeneous, stratified, and mixed), and the postoperative bowel wall behavior, classified as normalized, improved, unchanged, or worsened. RESULTS A significant correlation was found between a long preoperative bowel wall thickening and surgical recurrence. Bowel wall thickness after surgery was unchanged or worsened in 43.3% of patients; in these patients, there was a high frequency of previous surgery. Patients with unchanged or worsened bowel wall thickness had a higher risk of clinical and surgical recurrence compared with those with normalized or improved bowel wall thickness. CONCLUSION With the use of abdominal ultrasound, the authors found that the thickening of diseased bowel wall may unexpectedly improve after conservative surgery, and this is associated with a favorable outcome in terms of clinical and surgical recurrence. In addition to its diagnostic usefulness, ultrasound also provides reliable prognostic information concerning clinical and surgical recurrence in patients with Crohn's disease in the postoperative follow-up.
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Affiliation(s)
- G Maconi
- Gastrointestinal Unit, Università degli Studi di Milano, Ospedale Luigi Sacco, Milan, Italy
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Platell C, Mackay J, Woods R. A multivariate analysis of risk factors associated with recurrence following surgery for Crohn's disease. Colorectal Dis 2001; 3:100-6. [PMID: 12791002 DOI: 10.1046/j.1463-1318.2001.00213.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The aim of this study was to identify risk factors associated with the recurrence of Crohn's disease (CD) after definitive surgery. PATIENTS AND METHODS A retrospective review was conducted on 228 patients with histologically proven CD who had undergone surgery to remove macroscopic disease. Recurrence was defined as the requirement to undergo further surgery for symptomatic CD. Logistic linear regression was used to evaluate the relationship between 16 independent variables and the incidence of recurrent disease. RESULTS The male to female ratio was 1:1.3, the mean age at operation was 32 years (range 11-93 years), and the patients were followed post-operatively for a mean of 58 months (range 1-396 months). Survival analysis found that 29.2% of patients had a recurrence of CD at 5 years, and 46.0% at 10 years. Univariate analysis identified the following factors which were significant predictors for recurrence-an abscess as an indication for surgery, the absence of Mesalazine/Sulphasalazine therapy in the preoperative period, length of follow up, development of post-operative septic complications (abscess, anastomotic leak, fistula formation), and the presence of anal disease (perianal fistula, abscess, rectovaginal fistula, anal ulceration). The only significant independent predictors for recurrence were follow-up time (P=0.04, odds ratio (OR) 1.01, 95% confidence interval (CI) 1.00-1.01) and the absence of preoperative Mesalazine/Sulphasalazine therapy (P=0.05, OR 2.02, 95% CI 0.99-4.13). CONCLUSION The results suggest that the use of Mesalazine/Sulphasalazine before surgery influenced the subsequent recurrence of CD. The clinical relevance of this observation requires further validation.
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Affiliation(s)
- C Platell
- University Department of Surgery at Fremantle Hospital, Perth, Australia.
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Muñoz-Juárez M, Yamamoto T, Wolff BG, Keighley MR. Wide-lumen stapled anastomosis vs. conventional end-to-end anastomosis in the treatment of Crohn's disease. Dis Colon Rectum 2001; 44:20-5; discussion 25-6. [PMID: 11805559 DOI: 10.1007/bf02234814] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Preanastomotic recurrence and stricturing after surgery for ileocolic Crohn's disease is a frequent, unexplained phenomena that may lead to prompt reoperation. The aim of this study was to determine whether a wide-lumen stapled anastomosis (side-to-side, functional end-to-end) provides better outcome than a conventional sutured end-to-end anastomosis METHOD A case-control comparative analysis of patients with Crohn's disease from two inflammatory bowel disease centers treated with wide-lumen stapled anastomosis and a matched (age and gender) group treated with conventional sutured end-to-end anastomosis was performed. RESULTS A total of 138 patients with Crohn's disease were treated, 69 with wide-lumen stapled anastomosis and 69 with conventional sutured end-to-end anastomosis. Preoperative therapy, number of previous resections, indication for operation, and length of bowel resected were similar in both groups. Fewer complications occurred after wide-lumen stapled anastomosis (P = 0.048). A total of 55 patients developed recurrent Crohn's disease symptoms, 39 (57 percent) in the conventional sutured end-to-end anastomosis and 16 (24 percent) in the wide-lumen stapled anastomosis group. Median follow-up was 70 and 46 months, respectively. After conventional sutured end-to-end anastomosis 18 reoperations were required, 15 for anastomotic stricture and 3 for fistulization. After wide-lumen stapled anastomosis three reoperations were necessary, two for stricture and one for fistulization. The cumulative reoperation rate for anastomotic recurrence was significantly lower (P = 0.017; log-rank test) for the wide-lumen stapled anastomosis group. CONCLUSION Wide-lumen stapled anastomosis is as safe as conventional sutured end-to-end anastomosis and results in a lower incidence of symptomatic recurrent Crohn's disease and need for reoperation. Further prospective study of the wide-lumen stapled anastomosis technique is necessary to define the precise role of this operation in patients with Crohn's disease.
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Affiliation(s)
- M Muñoz-Juárez
- Division of Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Bernell O, Lapidus A, Hellers G. Risk factors for surgery and recurrence in 907 patients with primary ileocaecal Crohn's disease. Br J Surg 2000; 87:1697-701. [PMID: 11122187 DOI: 10.1046/j.1365-2168.2000.01589.x] [Citation(s) in RCA: 249] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previous studies on risk factors for resection and postoperative recurrence in Crohn's disease have given inconclusive results. The aim of this study was to assess the risk for resection and postoperative recurrence in the treatment of ileocaecal Crohn's disease and to define factors affecting the course of the disease. METHODS A population-based cohort of 907 patients with primary ileocaecal Crohn's disease was reviewed retrospectively. RESULTS Resection rates were 61, 77 and 83 per cent at 1, 5 and 10 years respectively after the diagnosis. Relapse rates were 28 and 36 per cent 5 and 10 years after the first resection. A younger age at diagnosis resulted in a low resection rate. The presence of perianal Crohn's disease and long resection segments increased the incidence of recurrence, and resection for a palpable mass and/or abscess decreased the recurrence rate. A decrease in recurrence rate during the study period (1955-1989) was observed. CONCLUSION In ileocaecal Crohn's disease the probability of resection is high and the risk of recurrence moderate. Crohn's disease in childhood carries a lower risk of primary resection. Perianal disease and extensive ileal resection increase the risk of recurrence.
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Affiliation(s)
- O Bernell
- Departments of Surgery and Gastroenterology, Karolinska Institute, Huddinge University Hospital, S-141 86 Huddinge, Sweden
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Bresci G, Parisi G, Bertoni M, Masolino P, Scatena F, Capria A. Does the initial location of Crohn's disease have an influence on the time-to-relapse in patients under maintenance treatment with oral mesalamine? J Clin Gastroenterol 2000; 31:147-51. [PMID: 10993432 DOI: 10.1097/00004836-200009000-00012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
The aim of this study was to determine the possible influence of the initial location of Crohn's disease (CD) on the time-to-relapse in patients with quiescent CD treated only with oral mesalamine (5-ASA). We divided 74 consecutive patients in clinical remission into three groups according to the initial location of CD. Group A consisted of 30 cases with an ileal location; group B, 18 with ileocolonic location; and group C, 26 with a colonic location. The patients entered the study if they were in clinical and endoscopic remission for at least 3 months. Relapse was defined by CD Activity Index > or = 150, CD Endoscopic Index of Severity > or =4, and by an abnormal increase of C-reactive protein, white blood cell count, and erythrocyte sedimentation rate; moreover, if it was confirmed by x-ray and/or endoscopy. Time-to-relapse was defined as the interval between the date of enrollment and the date of relapse. The patients with an ileal location showed a relapse within 5 years, with a time-to-relapse of 1 year in 26% of cases, 2 years in 85%, 3 years in 92%, and 4 years in 96%. The patients with ileocolonic location showed a relapse within 4 years, with time-to-relapse of 1 year in 39% of cases, 2 years in 89%, and 3 years in 94%. The cases with a colonic location showed a relapse within 6 years, with time-to-relapse of 1 year in 33% of cases, 2 years in 71%, 3 years in 79%, and 4 years in 87%. Surgical treatment was necessary in 37% of the cases with an ileal location, in 44% with ileocolonic location, and 17% with a colonic location. In conclusion, even if our data lack a statistical significance, we have found that the initial anatomic involvement is not a valid parameter to predict the relapse risk in a homogeneous group under continuous treatment with oral 5-ASA, although ileocolonic location seems to have a more aggressive course.
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Affiliation(s)
- G Bresci
- Department of Gastroenterology, Azienda Ospedaliera Pisana, Italy.
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Cristaldi M, Sampietro GM, Danelli PG, Bollani S, Bianchi Porro G, Taschieri AM. Long-term results and multivariate analysis of prognostic factors in 138 consecutive patients operated on for Crohn's disease using "bowel-sparing" techniques. Am J Surg 2000; 179:266-70. [PMID: 10875983 DOI: 10.1016/s0002-9610(00)00334-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Conservative surgery has become accepted as a useful option for the surgical treatment of complicated Crohn's disease (CD). METHODS One hundred thirty-eight consecutive patients treated with strictureplasty or miniresections for complicated CD have been observed prospectively. The possible influence of a number of variables on the risk of recurrence was investigated using the Cox proportional hazard model, and a time-to-event analysis was made using the Kaplan-Meier function. RESULTS There was no perioperative mortality; the morbidity rate was 5.7%. A close correlation was found between the risk of recurrence and the time between diagnosis and first surgery. The overall 5-year recurrence rate was 24%, being 36% in the patients requiring surgery within 1 year of diagnosis and 14% in those operated on more than 1 year after diagnosis. CONCLUSIONS Risk factor analysis highlighted a group of patients at high risk of surgical recurrence. Given that our results are similar to those reported in other series, we consider strictureplasty and miniresections safe and effective procedures for the treatment of complicated CD.
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Affiliation(s)
- M Cristaldi
- Division of General Surgery, Università degli Studi di Milano, Istituto di Scienze Biomediche, Ospedale Luigi Sacco, Milan, Italy
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Hashemi M, Novell JR, Lewis AA. Side-to-side stapled anastomosis may delay recurrence in Crohn's disease. Dis Colon Rectum 1998; 41:1293-6. [PMID: 9788394 DOI: 10.1007/bf02258231] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE Perianastomotic recurrence after resection in Crohn's disease may be related to ischemia and subacute obstruction at the anastomosis. A technique designed to minimize these factors currently is being evaluated. METHODS From 1984 to 1997 69 patients underwent resection and primary anastomosis for symptomatic Crohn's disease (17 jejunal or ileal, 72 ileocolic, and 7 colocolic resections). Of these, 42 patients underwent functional end-to-end anastomoses with the use of linear cutting staplers (Proximate 75 mm or GIA 228 80 mm) and 27 patients underwent end-to-end sutured anastomoses. RESULTS In the stapled anastomosis group one (2 percent) patient required reoperation for recurrent symptoms at 46 months. Complications occurred in four (8 percent) patients (one enterocutaneous fistula, one wound infection, one abscess, and one ileus). There were no anastomotic leaks. The median postoperative stay was seven (range, 5-26) days. In the sutured anastomosis group 14 (43 percent) patients required 15 further resections for symptomatic recurrence at a median of 46 (range, 4-91) months. Complications occurred in six (17 percent) patients (two anastomotic leaks, two fistulas, one stricture, and one pulmonary embolus). The median postoperative stay was 10 (range, 6-28) days. CONCLUSIONS Functional end-to-end stapled anastomoses after resection for Crohn's disease may be associated with fewer complications than sutured anastomoses and may delay reoperation for symptomatic recurrence. Further evaluation of the technique is indicated.
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Affiliation(s)
- M Hashemi
- Department of Surgery, Luton and Dunstable Hospital NHS Trust, Bedfordshire, United Kingdom
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