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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: 136] [Impact Index Per Article: 10.5] [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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2
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Predicting, treating and preventing postoperative recurrence of Crohn's disease: the state of the field. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2011; 25:140-6. [PMID: 21499578 DOI: 10.1155/2011/591347] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The majority of patients diagnosed with Crohn's disease eventually require surgical intervention. Unfortunately, postsurgical remission tends to be short lived; a significant number of patients experience clinical relapse and many require additional operations. The pathogenesis of this postoperative recurrence is poorly understood and, currently, there are no reliable tools to predict when and in whom the disease will recur. Furthermore, the postoperative prophylaxis profiles of available Crohn's disease therapeutic agents such as 5-aminosalicylates, immunomodulators, steroids and probiotics have been disappointing. Recently, the combination of antibiotics and azathioprine in selected high-risk patients has demonstrated some potential for benefit. The goal of the present article is to provide a coherent summary of previous and new research to guide clinicians in managing the challenging and complex problem of postoperative Crohn's disease recurrence.
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Cunningham MF, Docherty NG, Coffey JC, Burke JP, O'Connell PR. Postsurgical recurrence of ileal Crohn's disease: an update on risk factors and intervention points to a central role for impaired host-microflora homeostasis. World J Surg 2011; 34:1615-26. [PMID: 20195604 DOI: 10.1007/s00268-010-0504-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND A pressing need exists to identify factors that predispose to recurrence after terminal ileal resection for Crohn's disease (CD) and to determine effective prophylactic strategies. This review presents an up-to-date summary of the literature in the field and points to a role for bacterial overproliferation in recurrence. METHODS The literature (Medline, Embase, and the Cochrane Library, 1971-2009) on ileal CD and postoperative recurrence was searched, and 528 relevant articles were identified and reviewed. RESULTS Smoking is a key independent risk factor for recurrence. NOD2/CARD15 polymorphisms and penetrating phenotype are associated with aggressive disease and higher reoperation rates. Age at diagnosis, disease duration, gender, and family history are inconsistent predictors of recurrence. Prophylactic 5-aminosalicylic acid therapy and nitromidazole antibiotics are beneficial. Combination therapies with immunosuppressants are also effective. Anti-TNFalpha-based regimens show benefit but the evidence base is small. Corticosteroid, interleukin-10, and probiotic therapies are not effective. Wider, stapled anastomotic configurations are associated with reduced recurrence rates. Strictureplasty and laparoscopic approaches have similar long-term recurrence rates to open resection techniques. Length of resection and presence of microscopic disease at resection margins do not influence recurrence. A lack of consensus exists regarding whether the presence of granulomas or plexitis affects outcome. CONCLUSIONS Current evidence points to defects in mucosal immunity and intestinal dysbiosis of either innate (NOD2/CARD15) or induced (smoking) origin in postoperative CD recurrence. Prophylactic strategies should aim to limit dysbiosis (antibiotics, side-to-side anastomoses) or prevent downstream chronic inflammatory sequelae (anti-inflammatory, immunosuppressive, and immunomodulatory therapy).
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Affiliation(s)
- Michael F Cunningham
- Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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4
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Abstract
With the advent of restorative proctocolectomy or ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), not only has there been potential for cure of UC but also patients have enjoyed marked improvements in bowel function, continence, and quality of life. However, IPAA can be complicated by postoperative small bowel obstruction, disease recurrence, and pouch failure secondary to pelvic sepsis, pouch dysfunction, mucosal inflammation, and neoplastic transformation. These may necessitate emergent or expeditious elective reoperation to salvage the pouch and preserve adequate function. Local, transanal, and transabdominal approaches to IPAA salvage are described, and their indications, outcomes, and the clinical parameters that affect the need for salvage are discussed. Pouch excision for failed salvage reoperation is reviewed as well. Relaparotomy is also frequently required for recurrent Crohn's disease (CD), especially given the nature of this as yet incurable illness. Risk factors for CD recurrence are examined, and the various surgical options and margins of resection are evaluated with a focus on bowel-sparing policy. Stricturoplasty, its outcomes, and its importance in recurrent disease are discussed, and segmental resection is compared with more extensive procedures such as total colectomy with ileorectal anastomosis. Lastly, laparoscopy is addressed with respect to its long-term outcomes, effect on surgical recurrence, and its application in the management of recurrent CD.
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Affiliation(s)
- Rowena L Ramirez
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Sachar DB, Lemmer E, Ibrahim C, Edden Y, Ullman T, Ciardulo J, Roth E, Greenstein AJ, Bauer JJ. Recurrence patterns after first resection for stricturing or penetrating Crohn's disease. Inflamm Bowel Dis 2009; 15:1071-5. [PMID: 19229992 DOI: 10.1002/ibd.20872] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Crohn's disease (CD) usually recurs after resection, but the factors associated with this risk remain obscure. We set out to determine the role of stricturing (Montreal Classification B2) versus penetrating (Classification B3) disease behavior in predicting early (<3 years) versus late (>or=3 years) postoperative recurrence. METHODS We identified a cohort of 34 patients seen at The Mount Sinai Hospital who had undergone a first ileocolic resection prior to December 31, 2004, who had been clinically thought to have had stricturing (B2) disease, and for whom we could verify 1) the operative and surgical pathology findings; and 2) the time of onset of symptoms attributable to recurrent CD by endoscopy, radiology, or surgery. Cases were reclassified as either "stricturing" (B2) or "penetrating" (B3) on the basis of operative and surgical pathology reports. Recurrences were classified as either "early" (<3 years) or "late" (>or=3 years) depending on the first appearance of postoperative symptoms that were verified endoscopically and histologically, radiologically, or surgically as being attributable to anastomotic recurrence of the CD. RESULTS Among these 34 patients clinically thought to have had B2 disease, 12 had B2 disease confirmed upon review of surgical and pathology reports and none of them had recurrence within 3 years. Among the 22 patients reclassified as B3 disease, 12 (55%) had early recurrence. This difference was significant at the 0.002 level by the Fisher Exact Test. CONCLUSIONS There is a strong proclivity for early postoperative recurrence of penetrating CD compared to stricturing disease, which may not be evident by behavioral classification on clinical grounds alone. Patients with confirmed uncomplicated stricturing obstruction at their first resection seem unlikely to experience a clinical recurrence within the next 3 years.
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Affiliation(s)
- David B Sachar
- Department of Medicine, Division of Gastroenterology, Mount Sinai School of Medicine, New York, New York 10029-6574, USA.
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6
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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: 138] [Impact Index Per Article: 8.1] [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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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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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: 16] [Impact Index Per Article: 0.9] [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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9
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Abstract
Despite advances in medical treatment, most patients who have Crohn's disease of the small intestine need surgery at some point during the course of their disease. Surgery is currently indicated for intractable disease and complications of the disease (strictures, abscesses, fistulas, hemorrhage). There is increasing interest in nonsurgical and minimal access strategies of dealing with complicated disease, however. These new approaches may enable postponement of surgery to a more favorable time, or conversion of a two-stage procedure involving a stoma to a one-stage resection with anastomosis. A continuing challenge is prevention of disease recurrence postoperatively.
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Affiliation(s)
- Keith R Gardiner
- Royal Victoria Hospital, Grosvenor Road, Belfast, Northern Ireland, UK.
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10
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Kurer MA, Stamou KM, Wilson TR, Bradford IMJ, Leveson SH. Early symptomatic recurrence after intestinal resection in Crohn's disease is unpredictable. Colorectal Dis 2007; 9:567-71. [PMID: 17573754 DOI: 10.1111/j.1463-1318.2006.01202.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To identify predictors of early symptomatic recurrence of Crohn's disease (CD) after surgical resection. METHOD We studied a cohort of 128 patients who had undergone at least one intestinal resection for CD. Factors that might predict early recurrence were documented for analysis using a standardized pro forma. These comprised age, gender, family history, extra-intestinal manifestations, smoking, complicated disease at first presentation, site of disease, preoperative inflammatory markers, involvement of resection margins, orientation and method of anastomosis and postoperative medical therapy. All symptomatic recurrences were confirmed by endoscopic, radiological, or operative means. We defined early recurrence as that which occurred within 36 months of first surgery. Univariate analysis was conducted to compare the distribution of each factor in those who developed early recurrence (n = 48) and those who remained disease free for the first 36 months (n = 50). RESULTS Of the 128 patients studied, 98 fulfilled the inclusion criteria of at least 36 months of follow up. Of these patients, 48 (49%) patients developed recurrence. Trends towards fewer early recurrences were seen in patients with colonic disease (33%vs 56%, P = 0.068). Of the current smokers, 60% developed early recurrence compared with 43% of nonsmokers (P = 0.269). All other factors examined were similarly distributed between the two groups. Metronidazole as adjuvant treatment does not appear to protect against early symptomatic recurrence. CONCLUSION This study shows that early symptomatic postoperative recurrence of CD remains unpredictable. Against expectation, abstinence from smoking and postoperative adjuvant metronidazole did not appear to protect against early symptomatic recurrence.
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Affiliation(s)
- M A Kurer
- Academic Department of Surgery, York Hospital, York, UK.
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11
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Fazio VW. Indications and Strategies for the Surgery of Crohn’s Disease. SEMINARS IN COLON AND RECTAL SURGERY 2007. [DOI: 10.1053/j.scrs.2006.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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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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Etienney I, Bouhnik Y, Gendre JP, Lémann M, Cosnes J, Matuchansky C, Beaugerie L, Modigliani R, Rambaud JC. Crohn's disease over 20 years after diagnosis in a referral population. ACTA ACUST UNITED AC 2004; 28:1233-9. [PMID: 15671934 DOI: 10.1016/s0399-8320(04)95216-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Patients frequently ask questions about the lifetime prognosis of Crohn's disease. The aim of this study was to describe the outcomes of Crohn's disease more than 20 years after diagnosis. METHODS Data from all patients with Crohn's disease whose diagnosis had been performed before 1st January 1978 were analyzed. All referred patients filled in a medical and health-related quality-of-life questionnaire. RESULTS Among 273 patients with Crohn's disease diagnosed more than 20 years ago, 141 (52%) patients answered our questionnaire, 45 (16%) patients were alive but did not wish to answer our questionnaire, 51 (19%) could not be traced and 36 (13%) died before July 1998. At the end of follow-up, 25.7 (20.0-59.3) years after diagnosis, 24% had a relapse in the previous 12 months, and 48% and 28% had quiescent disease with and without treatment, respectively. These ratios were not different from those observed three years after Crohn's disease diagnosis. Sixteen patients died within 20 years after CD diagnosis, including 11 from CD-related causes. The risk of death estimated by Kaplan-Meier life-tables analysis was non-significantly higher if death was related to CD. An ileal or colic adenocarcinoma was noted in 6 (3.4%) patients. CONCLUSIONS Crohn's disease activity does not burn out with time, and roughly one-quarter of the patients had active disease 20 years after diagnosis.
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Affiliation(s)
- Isabelle Etienney
- Hépato-Gastroentérologie et Assistance Nutritive, Hôpital Lariboisière, Paris
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14
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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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15
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Borley NR, Mortensen NJM, Chaudry MA, Mohammed S, Clarke T, Jewell DP. Evidence for separate disease phenotypes in intestinal Crohn's disease. Br J Surg 2002. [DOI: 10.1046/j.1365-2168.2002.01987.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Background
This study investigated the hypothesis that separate phenotypes of Crohn's disease exist which display differing patterns of recurrence with a tendency to preservation of phenotype between serial operations.
Methods
Some 483 abdominal operations (278 patients) were identified from a prospectively compiled database. Patterns of recurrence (reoperation) were analysed by Kaplan–Meier plots and log rank tests according to disease phenotype (perforated, stenosed or ulcerated). Serial operations were analysed by agreement of phenotype and microscopic features of disease using kappa statistics and correlation coefficients.
Results
There was no significant difference in recurrence according to disease phenotype (median reoperation-free survival time 43·0, 50·2 and 47·9 months for perforated, stenosed and ulcerated types respectively; log rank χ2 = 3·5, P = 0·18). There was poor agreement in phenotype between serial operations (κ = 0·22 for first/second operation and κ = 0·15 for second/third operation) and no significant correlation between pathological features was identified (r between −0·19 and 0·48).
Conclusion
No evidence was found for the existence of separate disease phenotypes with differing natural histories or underlying pathological characteristics.
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Affiliation(s)
- N R Borley
- Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, UK
| | - N J McC Mortensen
- Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, UK
| | - M A Chaudry
- Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, UK
| | - S Mohammed
- Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, UK
| | - T Clarke
- Centre for Statistics in Medicine, Oxford, UK
| | - D P Jewell
- Department of Gastroenterology, John Radcliffe Hospital, Oxford, UK
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Cosnes J, Cattan S, Blain A, Beaugerie L, Carbonnel F, Parc R, Gendre JP. Long-term evolution of disease behavior of Crohn's disease. Inflamm Bowel Dis 2002; 8:244-50. [PMID: 12131607 DOI: 10.1097/00054725-200207000-00002] [Citation(s) in RCA: 966] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Vienna classification of Crohn's disease (CD) distinguishes three patient subgroups according to disease behavior: stricturing, penetrating, and inflammatory. Our aim was to assess the long-term evolution of the disease behavior of CD and to determine the predictive factors and prognostic implications of this evolution. METHODS Occurrence and predictive factors of a stricturing and/or a penetrating complication were searched for in 2,002 patients with CD studied retrospectively. In addition, the 1995-2000 disease course was assessed prospectively in a cohort of 646 patients with disease duration >5 years, classified according to their previous disease behavior. RESULTS 1,199 patients (60%) developed a stricturing (n = 254) or a penetrating (n = 945) complication. Twenty-year actuarial rates of inflammatory, stricturing, and penetrating disease were 12, 18, and 70%, respectively. The initial location of lesions was the main determinant of the time and type of the complication. In the cohort study, year-by-year activity and therapeutic requirements did not show significant sustained differences between behavioral subgroups. CONCLUSION Most patients with CD will eventually one day develop a stricturing or a perforating complication. Initial location determines the type of the complication. Classification of patients into a behavioral group from previous history has no impact upon activity during the following years.
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Affiliation(s)
- Jacques Cosnes
- Service d'Hépatogastroentérologie et Nutrition, Hôpital Rothschild, Paris, France.
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Allez M, Lemann M, Bonnet J, Cattan P, Jian R, Modigliani R. Long term outcome of patients with active Crohn's disease exhibiting extensive and deep ulcerations at colonoscopy. Am J Gastroenterol 2002; 97:947-53. [PMID: 12003431 DOI: 10.1111/j.1572-0241.2002.05614.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Prediction of the clinical course of Crohn's disease (CD) is difficult in the long term. Our aim was to determine whether the presence of severe endoscopic lesions (SELs) may predict a higher risk of colectomy and penetrating complications. METHODS All patients at our institution with active ileocoIonic CD who had colonoscopies between 1990 and 1996 were included in the study. SELs were defined as extensive and deep ulcerations covering more than 10% of the mucosal area of at least one segment of the colon. RESULTS Among the 102 patients included, 53 had SELs at index colonoscopy. During the follow-up (median = 52 months), 37 patients underwent colonic resection. Probabilities of colectomy at 1, 3, and 8 yr were 20%, 26%, and 42%. Risk of colectomy was independently affected by the presence of SELs at index colonoscopy (relative risk [RR] = 5.43, 95% CI = 2.64-11.18), a Crohn's Disease Activity Index level greater than 288 (RR = 2.21, 95% CI = 1.09-4.47), and the absence of immunosuppressive therapy during the follow-up (RR = 2.44, 95% CI = 1.20-5.00). Probabilities of colectomy were, respectively, 31% and 6% at 1 yr, 42% and 8% at 3 yr, and 62% and 18% at 8 yr in patients with and without SELs. We performed a second analysis excluding the 14 patients operated on within the 3 months after the index colonoscopy: presence of SELs remained the only significant factor predictive of colectomy (RR = 6.72, 95% CI = 2.26-20.03). All six patients with penetrating complications during the follow-up had SELs at index colonoscopy. CONCLUSIONS Patients with CD exhibiting deep and extensive ulcerations at colonoscopy have a more aggressive clinical course with an increased rate of penetrating complications and surgery.
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Affiliation(s)
- Matthieu Allez
- Service de Gastroentérologie, Hôpital Saint-Louis, Paris, France
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Achkar JP, Shen B. Medical management of postoperative complications of inflammatory bowel disease: pouchitis and Crohn's disease recurrence. Curr Gastroenterol Rep 2001; 3:484-90. [PMID: 11696286 DOI: 10.1007/s11894-001-0069-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Surgical intervention is often required for patients with inflammatory bowel disease. Total proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for patients with ulcerative colitis. The main long-term complication of this surgery is pouchitis, with 10-year cumulative incidence rates between 24% and 46%. For patients with Crohn's disease, postoperative recurrence is a significant problem, with clinical recurrence rates as high as 55% at 5 years and 76% at 15 years. Increasing evidence suggests that postoperative medical therapy has the potential to decrease the risk of postoperative Crohn's disease recurrence.
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Affiliation(s)
- J P Achkar
- Department of Gastroenterology, The Cleveland Clinic Foundation, A30, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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19
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Gulías Piñeiro A, Madriñán González M, Prego Mateo E. [Acute peritonitis due to perforating crohn's disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2001; 24:346-8. [PMID: 11481070 DOI: 10.1016/s0210-5705(01)70191-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Peritonitis is an infrequent complication of perforating Crohn's disease. Three patients, aged between 25 and 41 years, underwent surgery for peritonitis due to perforating Crohn's disease in the terminal ileum. The underlying disease differed in each patient (one patient was asymptomatic and two presented acute episodes of the disease; of these two patients, corticoids were required in one to control symptomatology). Treatment consisted of intestinal resection with primary anastomosis. In all three patients evolution was satisfactory. Taking only patients treated in our hospital into account, the frequency of peritonitis due to perforating Crohn's disease in our area is high (more than 11%). Intestinal resection with primary anastomosis should be performed whenever possible.
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Affiliation(s)
- A Gulías Piñeiro
- Servicio de Cirugía General y del Aparato Digestivo, F.P. Hospital Virxe da Xunqueira de Cee, A Coruña, Spain
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20
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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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Hinojosa J, Nos P, Ramírez JJ, Hoyos M, Molés JR, Ponce J, Berenguer J. Evolutive pattern in Crohn's disease: a simplified index using clinical parameters predicts obstructive behaviour. Eur J Gastroenterol Hepatol 2001; 13:245-9. [PMID: 11293443 DOI: 10.1097/00042737-200103000-00005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Two clearly differentiated evolutive patterns of Crohn's disease, obstructive and fistulizing, exist, but the early clinical parameters which can predict the evolution are unknown. AIM To evaluate whether clinical variables, present at the time of diagnosis, may help in predicting a subsequent evolutive behaviour. PATIENTS AND METHODS Ninety out of 140 evaluable patients were included. After a median of 50.2 months since diagnosis, 64 patients (71%) followed an obstructive pattern while 26 patients (28.9%) had a fistulizing form. Clinical variables were analysed as predictors of outcome. Logistic regression was carried out in order to obtain a mathematical model that would predict the evolution. The individual ability of the mathematical model to predict evolution was assessed using relative receiver operating characteristic (ROC) curves. RESULTS The variables which were retained in the model were duration of disease before diagnosis (DD), onset of symptoms (OS), presence of anal disease (AD) and the presence of abdominal mass (AM). The equation z = -9.49 + 2.2643 (AD) - 0.0066 (DD) + 2.5282 (AM) + 1.3433 (OS) was obtained. The probability of evolution towards an obstructive form was P = 1/(1 + e(-Z)). This model can predict 96.88% of obstructive forms but only 53.85% of fistulizing forms. The mathematical point section (ROC curve) corresponds to a probability of 45.2%. Considering an obstructive pattern when the probabilities are above this point, the sensitivity is 98% and the specificity is 50%. CONCLUSIONS The prediction of an obstructive pattern is feasible using simple clinical variables. The mathematical model obtained is useful for predicting this but not the fistulizing pattern.
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Affiliation(s)
- J Hinojosa
- Department of Gastroenterology, Hospital of Sagunto, Valencia, Spain.
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22
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Abstract
Crohn's disease of the small bowel frequently requires surgical intervention. While dealing with the disease complications that require intervention, treatment should be based on a long-term strategic plan that recognizes the likelihood of recurrent disease, repeat surgeries, and the possibility of a future ostomy. Resection forms the basis for surgical treatments, but strictureplasty, abscess drainage, intestinal and diversion bypasses also are used, selectively.
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Affiliation(s)
- C P Delaney
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio 44195, USA.
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23
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Abstract
Clinical recurrence of Crohn's disease after surgical resection is a significant problem, with reported rates as high as 55% at 5 yr and 76% at 15 yr. Specific factors that predispose to postoperative recurrence of Crohn's disease have not been well defined. In addition, the underlying pathophysiology of recurrent disease and the reason for its localization to the neoterminal ileum are not well understood. Various operative techniques have been evaluated but none, aside from formation of an ostomy, has been shown to reduce the risk of recurrence. In contrast, there is increasing evidence that postoperative medical therapy has the potential to decrease the risk of postoperative recurrence. Historically, sulfasalazine may have a modest effect on reducing postoperative recurrence of ileal or ileocolonic disease. However, 5-ASA preparations that can selectively deliver mesalamine to the small bowel or anastomotic margin should be more effective. Indeed, in several studies and as confirmed by a meta-analysis, mesalamine has been demonstrated to reduce significantly postoperative recurrence of Crohn's disease. Metronidazole and 6-mercaptopurine or azathioprine also seem to be of benefit in postoperative prophylaxis of disease recurrence, but additional controlled studies are required to define better the efficacy and dose-response of these agents. Corticosteroids are ineffective at reducing postoperative recurrence.
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Affiliation(s)
- J P Achkar
- Department of Gastroenterology, The Cleveland Clinic Foundation, Ohio 44195, USA
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Yamamoto T, Allan RN, Keighley MR. Perforating ileocecal Crohn's disease does not carry a high risk of recurrence but usually re-presents as perforating disease. Dis Colon Rectum 1999; 42:519-24. [PMID: 10215055 DOI: 10.1007/bf02234180] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE The aim of this study was to study the natural history of perforating and nonperforating ileocecal Crohn's disease. METHODS One hundred sixty-five cases of primary ileocecal Crohn's disease operated on between 1975 and 1995 were reviewed. Perforating disease was defined as acute free perforation, subacute perforation with an abscess, or chronic perforation with an internal or external fistula. RESULTS Perforating disease was identified in 72 patients (44 percent); 11 with acute free perforation, 18 with abscess formation, and 43 with fistulas. Postoperative complications occurred in 29 percent of perforating and in 23 percent of nonperforating disease (not a significant difference). There was no significant difference in the cumulative reoperation-free rate for recurrence at the ileocolonic anastomosis (perforating, 78 percent vs. nonperforating, 73 percent at 5 years and perforating, 61 percent vs. nonperforating, 55 percent at 10 years), or in the median time interval from the primary to the secondary operation (perforating, 49 vs. nonperforating, 37 months). Seventy percent of perforating disease re-presented with perforating recurrence. Likewise, 83 percent of nonperforating disease re-presented with nonperforating (P < 0.0001) recurrence. Re-reoperation rate for re-recurrence at the ileocolonic anastomosis and median duration from the second operation to the third operation did not differ between perforating and nonperforating disease. Seventy-nine percent of perforating disease re-presented again with perforating disease, and 87 percent of nonperforating disease re-presented again with nonperforating disease as before (P = 0.001). CONCLUSIONS These data suggest that perforating ileocecal disease usually re-presents in the way it did originally but does not represent a high-risk group for recurrence.
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Affiliation(s)
- T Yamamoto
- University Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom
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25
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Abstract
BACKGROUND & AIMS Despite many advances in our understanding of Crohn's disease, the course of the disease in any given patient remains unpredictable. There is little agreement as to which factors increase a patient's risk of early postoperative recurrence. We have attempted to identify predictors of early recurrence after surgical resection, specifically whether the indication for initial surgery (perforating or nonperforating) or the duration of preoperative disease may be associated with early recurrence. METHODS We studied 88 patients who had undergone at least two resections for Crohn's disease. Multivariable survival analysis was performed to elucidate predictors of early postoperative recurrence. RESULTS A perforating indication for initial surgery (P < 0.001) and a longer preoperative disease duration (P = 0.004) were found to be the only independent predictors of earlier postoperative recurrence after initial surgery. A longer preoperative disease duration also showed a borderline significant association with a shorter interval from second to third surgery (P = 0.075). Finally, the indication for initial surgery was predictive of the indication at a subsequent surgery for recurrence (P = 0.001). CONCLUSIONS A perforating indication for initial resection and a longer duration of disease before initial surgery predicted an earlier postoperative recurrence. The latter association was borderline. This suggests that prognostic groups based on these factors may help to stratify patients with regard to risk of early recurrence.
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Affiliation(s)
- E Lautenbach
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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27
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Mishina D, Katsel P, Brown ST, Gilberts EC, Greenstein RJ. On the etiology of Crohn disease. Proc Natl Acad Sci U S A 1996; 93:9816-20. [PMID: 8790414 PMCID: PMC38512 DOI: 10.1073/pnas.93.18.9816] [Citation(s) in RCA: 127] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Crohn disease (CD) is a chronic, panenteric intestinal inflammatory disease. Its etiology is unknown. Analogous to the tuberculoid and lepromatous forms of leprosy, CD may have two clinical manifestations. One is aggressive and fistulizing (perforating), and the other is contained, indolent, and obstructive (nonperforating) [Gi]-berts, E. C. A. M., Greenstein, A. J., Katsel, P., Harpaz, N. & Greenstein, R. J. (1994) Proc. Natl. Acad. Sci. USA 91, 12721-127241. The etiology, if infections, may be due to Mycobacterium paratuberculosis. We employed reverse transcription PCR using M. paratuberculosis subspecies-specific primers (IS 900) on total RNA from 12 ileal mucosal specimens (CD, n = 8; controls, n = 4, 2 with ulcerative colitis and 2 with colonic cancer). As a negative control, we used Myobacterium avium DNA, originally cultured from the drinking water of a major city in the United States. cDNA sequence analysis shows that all eight cases of Crohn's disease and both samples from the patients with ulcerative colitis contained M. paratuberculosis RNA. Additionally, the M. avium control has the DNA sequence of M. paratuberculosis. We demonstrate the DNA sequence of M. paratuberculosis from mucosal specimens from humans with CD. The potable water supply may be a reservoir of infection. Although M. paratuberculosis signal in CD has been previously reported, a cause and effect relationship has not been established. In part, this is due to conflicting data from studies with empirical antimycobacterial therapy. We conclude that clinical trials with anti-M. paratuberculosis therapy are indicated in patients with CD who have been stratified into the aggressive (perforating) and contained (nonperforating) forms.
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Affiliation(s)
- D Mishina
- Laboratory of Molecular Surgical Research, Veterans Affairs Medical Center, Bronx, NY 10468, USA
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28
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Post S, Herfarth C, Böhm E, Timmermanns G, Schumacher H, Schürmann G, Golling M. The impact of disease pattern, surgical management, and individual surgeons on the risk for relaparotomy for recurrent Crohn's disease. Ann Surg 1996; 223:253-60. [PMID: 8604905 PMCID: PMC1235113 DOI: 10.1097/00000658-199603000-00005] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The authors provide a multivariate analysis of a large single-center experience with limited surgery for Crohn's disease. SUMMARY BACKGROUND DATA During the past decade, the aim of surgery for Crohn's disease has shifted from radical operation, achieving inflammation-free margins of resection, to "minimal surgery," intended to remove just grossly inflamed tissue or performing strictureplasties. METHODS Seven hundred ninety-three cases of resection and/or strictureplasty in 689 individuals with histologically verified Crohn's disease were followed for a mean period of 50 months (range, 5-166 months). Two different end points were analyzed: 1) any relaparotomy for recurrent (or persistent) Crohn's disease and 2) relaparotomy for site-specific recurrence. More than 30 variables of patient/disease characteristics and surgical management were included in a proportional hazard model. RESULTS Five parameters were associated independently with the risk for relaparotomy: increased risk coincided with young age at onset of disease, involvement of jejunum, enterocutaneous fistula, or performed strictureplasty, and decreased risk followed ileocecal resection. Site-specific risks of reoperation were calculated on the basis of 1260 intestinal resections or anastomoses performed in these patients. Young age at onset, duodenal and jejunal involvement, presence of enterocutaneous or perianal fistula, and a single surgeon (of 23) were associated significantly with increased risk of regional recurrence but not strictureplasty or inflammation at margins of resection. CONCLUSIONS Limited surgery for Crohn's disease is not associated with increased risk of regional recurrence requiring reoperation. However, patients with juvenile onset, proximal small bowel disease, and some types of fistulae are at a considerable risk of experiencing early surgical recurrence.
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Affiliation(s)
- S Post
- Department of Surgery, University of Heidelberg, Germany
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29
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Aeberhard P, Berchtold W, Riedtmann HJ, Stadelmann G. Surgical recurrence of perforating and nonperforating Crohn's disease. A study of 101 surgically treated Patients. Dis Colon Rectum 1996; 39:80-7. [PMID: 8601362 DOI: 10.1007/bf02048274] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE This is a study of the long-term course of surgically treated Crohn's disease designed to identify prognostic factors predictive of the time course and probability of surgical recurrence. PATIENTS AND METHODS The study is based on the records of 101 patients admitted to our institution for surgical treatment of Crohn's disease from January 1, 1970 to December 31, 1985. Follow-up was complete in 97 (96 percent) and incomplete in 4 patients. Median follow-up from the date of first operation was 13.25 years. The cumulative probability of requiring surgical treatment for recurrent disease was calculated using the life table method and further analyzed with the log-rank test and Cox regression. RESULTS The time to reoperation in this series was not significantly influenced by sex, age at onset of symptoms, age at diagnosis, age at first operation, anatomic location, and number of sites involved at the time of first operation. The only variable that had a statistically significant effect on the time to reoperation was characterization of disease at the time of operation as being perforating (P) opposed to nonperforating (NP). Median interval between the first and second intestinal operation was 1.7 years for the P group and 13 years for the NP group (P value, 0.005), and the median time between any two operations undergone during the study period was 2 years for the P group and 9.9 years for the NP group (P = 0.0002). The risk of having to undergo reoperation for recurrence was greatest during the first two years after an operation, and this was mainly because of a short time to surgical recurrence in the P group of indications. Therefore, the yearly hazard of requiring further surgery was maintained at approximately 5 percent. CONCLUSION The cumulative probability of requiring a reoperation for patients undergoing surgery for the P type of Crohn's disease is significantly different from that of patients with NP indications. The risk of having to undergo further surgery is particularly high during the first two years following an operation for perforating disease. The concept of a relatively aggressive perforating type of Crohn's disease and a more indolent nonperforating type is confirmed by the results of this study.
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Affiliation(s)
- P Aeberhard
- Department of Surgery, Kantonsspital, Aarau, Switzerland
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Platell C, Mackay J, Collopy B, Fink R, Ryan P, Woods R. Crohn's disease: a colon and rectal department experience. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1995; 65:570-5. [PMID: 7661797 DOI: 10.1111/j.1445-2197.1995.tb01697.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This study reviewed a series of patients with Crohn's disease managed by surgeons of the Department of Colon and Rectal Surgery, St Vincent's Hospital, Melbourne, since 1978. There were 306 patients: 171 males and 135 females. The mean age at diagnosis was 33.4 years (ranger 11-93). The distribution of the disease was small bowel 32.3%, small bowel and colon 26.5%, colon 39.9%, and anal disease alone 1.6%. A total of 416 abdominal operations were performed on 204 patients. The commonest indications for surgery were failed medical therapy (21.9%), small bowel obstruction (15.9%), enteric fistula (10.1%), and intra-abdominal abscess (10.1%). The most frequently performed procedures were ileocolic resection with anastomosis (28.8%), small bowel resection (9.4%), and total colectomy and ileostomy (7.0%). Postoperative complications included anastomotic leaks in 4.0%, intra-abdominal abscess formation in 3.6%, and enterocutaneous fistulae developed in 6%. Three patients died during the review period. During follow up (mean 84.4), 30% of patients developed recurrence requiring further surgery at a mean of 72.7 months postoperatively. The most frequent site for a recurrence was the pre-anastomotic terminal ileum (61.7%). In conclusion, the majority of patients with Crohn's disease will require resectional surgery at some stage. This can be performed with a low mortality and morbidity, and a recurrence rate of around 5% per year.
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Affiliation(s)
- C Platell
- Department of Colon and Rectal Surgery, St Vincent's Hospital, Fitzroy, Victoria, Australia
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31
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Prognose des Morbus Crohn—Vorhersage der Operationswahrscheinlichkeit und des postoperativen Verlaufs. Eur Surg 1995. [DOI: 10.1007/bf02602268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Sakanoue Y, Horai T, Okamoto T, Hatada T, Shoji Y, Fujita S, Kusunoki M, Utsunomiya J. Lipocortin-present perforating and lipocortin-absent nonperforating Crohn's disease. Am J Surg 1992; 164:341-4. [PMID: 1415941 DOI: 10.1016/s0002-9610(05)80901-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
To investigate whether Crohn's disease has two different clinical forms, a relatively aggressive perforating type and a more indolent nonperforating type, we compared the concentrations of lipocortin and prostaglandin E2 (PGE2) in the inflamed mucosa of 12 patients with strictly controlled Crohn's disease with those found in histologically normal mucosa of control subjects. The inflamed mucosa obtained from eight patients with nonperforating Crohn's disease did not react with antilipocortin antibody on immune blot analysis. In contrast, the inflamed mucosa from four patients with perforating Crohn's disease, as well as that obtained from histologically normal controls, contained lipocortins. In addition, higher concentrations of intramucosal ileal and colonic PGE2 were found in patients with nonperforating Crohn's disease (902 +/- 454 pg/wet weight [WW] mg and 1,268 +/- 567 pg/WW mg, respectively) compared with normal controls (90.2 +/- 43.1 pg/WW mg and 173 +/- 76.5 pg/WW mg, respectively) (p less than 0.01). The difference in intramucosal ileal and colonic PGE2 levels between patients with perforating Crohn's disease (109.6 +/- 16.7 pg/WW mg and 252 +/- 34.4 pg/WW mg, respectively) and normal controls was not significant. These findings indicate that there may be two distinct patterns of Crohn's disease that differ in the amount of lipocortin present in the intestinal mucosa.
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Affiliation(s)
- Y Sakanoue
- Second Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
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33
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Williams JG, Wong WD, Rothenberger DA, Goldberg SM. Recurrence of Crohn's disease after resection. Br J Surg 1991; 78:10-9. [PMID: 1998847 DOI: 10.1002/bjs.1800780106] [Citation(s) in RCA: 117] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Recurrent Crohn's disease develops in most patients after surgical resection if the patient is followed for sufficient time. This review examines various aspects of recurrent Crohn's disease. It is concluded that Crohn's disease is a diffuse condition of the gastrointestinal tract and that radical resection of Crohn's disease does not prevent recurrence. Assorted factors thought to be associated with recurrence are examined and the relevance of these factors to the surgeon treating Crohn's disease is discussed.
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Affiliation(s)
- J G Williams
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis 55455
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34
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Sachar DB. The problem of postoperative recurrence of Crohn's disease. THE MEDICAL CLINICS OF NORTH AMERICA 1990. [PMID: 2404175 DOI: 10.1007/978-94-009-1980-8_14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Most patients with Crohn's disease eventually require an operation and the overwhelming majority will ultimately experience a postoperative recurrence at the anastomotic site. Endoscopic lesions can be seen at the anastomosis in 85 per cent of patients by 3 years after surgery. While only 40 to 50 per cent of postoperative patients will ever undergo a second operation, clinical manifestations of recurrent disease develop at a cumulative rate of about 10 per cent per year. Postoperative recurrences of Crohn's disease are well recognized even after total proctocolectomy and ileostomy, but rates are higher following reanastomotic procedures. Evidence accumulated from published observations over the past 20 years, reinforced by new data from The Mount Sinai Hospital, suggests that Crohn's disease may follow at least two different patterns: "aggressive" disease characterized primarily by fistulae and abscesses, early requirement for surgery, and relatively rapid fistulizing-type recurrence; versus "indolent" disease characterized mostly by fibrotic stenosis and strictures, late requirement for surgery, and relatively slower obstructive-type recurrence. Pathophysiologic investigations and clinical trials alike should take into account this duality of clinical patterns. Regardless of the patterns of recurrence, however, surgery performed for proper indications is almost invariably rehabilitating for people disabled by the ravages and complications of Crohn's disease.
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Affiliation(s)
- D B Sachar
- Mount Sinai School of Medicine (CUNY), New York
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35
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Abstract
Most patients with Crohn's disease eventually require an operation and the overwhelming majority will ultimately experience a postoperative recurrence at the anastomotic site. Endoscopic lesions can be seen at the anastomosis in 85 per cent of patients by 3 years after surgery. While only 40 to 50 per cent of postoperative patients will ever undergo a second operation, clinical manifestations of recurrent disease develop at a cumulative rate of about 10 per cent per year. Postoperative recurrences of Crohn's disease are well recognized even after total proctocolectomy and ileostomy, but rates are higher following reanastomotic procedures. Evidence accumulated from published observations over the past 20 years, reinforced by new data from The Mount Sinai Hospital, suggests that Crohn's disease may follow at least two different patterns: "aggressive" disease characterized primarily by fistulae and abscesses, early requirement for surgery, and relatively rapid fistulizing-type recurrence; versus "indolent" disease characterized mostly by fibrotic stenosis and strictures, late requirement for surgery, and relatively slower obstructive-type recurrence. Pathophysiologic investigations and clinical trials alike should take into account this duality of clinical patterns. Regardless of the patterns of recurrence, however, surgery performed for proper indications is almost invariably rehabilitating for people disabled by the ravages and complications of Crohn's disease.
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Affiliation(s)
- D B Sachar
- Mount Sinai School of Medicine (CUNY), New York
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36
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Abstract
The effect of perioperative blood transfusion on recurrence of Crohn's disease was investigated retrospectively in 60 patients with Crohn's disease who underwent small-bowel resection. 28 patients received 1-8 units of blood; the others were not transfused. Both groups were similar in age, duration of Crohn's disease, and preoperative serum albumin, but preoperative haemoglobin, length of intestine resected, and location of small-bowel involvement were different. The patients who received perioperative blood transfusion had a significantly lower recurrence rate by life-table analysis, although the site and greater length of bowel involvement in the transfused patients would normally indicate an increased likelihood of recurrence. 5 years after bowel resection, the cumulative recurrence rate in transfused patients was 19%, compared with 59% in controls. The immunosuppressive effect of blood transfusion may modify the progression of Crohn's disease.
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Affiliation(s)
- J G Williams
- Department of Surgery, University of Wales College of Medicine, Health Park, Cardiff
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