Patterns of ileal recurrence in Crohn's disease. A prospective randomized study

Management of Post-Operative Crohn's Disease: Knowns and Unknowns

Crohn's disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract characterized by relapsing-remission phases. CD often requires surgical intervention during its course, mainly ileo-cecal/ileo-colonic resection. However, surgery in CD is not curative and post-operative recurrence (POR) can happen. The management of CD after surgery presents challenges. Ensuring timely, effective, and safe therapy to prevent POR is essential but difficult, considering that approximately 20-30% of subjects may not experience endoscopic POR and that 40-50% will only exhibit intermediate lesions, which carry a low risk of mid- and long-term clinical and surgical POR. Currently, there are two accepted intervention strategies: early post-operative prophylactic therapy (systematically or based on the patient's risk of recurrence) or starting therapy after confirming endoscopic POR 6-12 months after surgery (endoscopy-driven prophylactic therapy). The risk of overtreatment lies in exposing patients to undesired adverse events, along with the costs associated with medications. Conversely, undertreatment may lead to missed opportunities to prevent bowel damage and the necessity for additional surgery. This article aims to perform a comprehensive review regarding the optimal strategy to reduce the risk of POR in CD patients and the current therapeutic options.

Results of the Eighth Scientific Workshop of ECCO: Pathophysiology and Risk Factors of Postoperative Crohn's Disease Recurrence after an Ileocolonic Resection

Postoperative recurrence [POR] after an ileocolonic resection with ileocolonic anastomosis is frequently encountered in patients with Crohn's disease. The 8th Scientific Workshop of ECCO reviewed the available evidence on the pathophysiology and risk factors for POR. In this paper, we discuss published data on the role of the microbiome, the mesentery, the immune system and the genetic background. In addition to investigating the causative mechanisms of POR, identification of risk factors is essential to tailor preventive strategies. Potential clinical, surgical and histological risk factors are presented along with their limitations. Emphasis is placed on unanswered research questions, guiding prevention of POR based on individual patient profiles.

Medical and Surgical Implications of Mesenteric Adipose Tissue in Crohn's Disease: A Review of the Literature

Mesenteric adipose tissue (MAT) has gained substantial attention as an active player in Crohn's disease (CD), but its clinical significance is poorly understood and likely reflects, in part, difficulties assessing MAT noninvasively. Recent radiologic studies have identified candidate surrogate markers that may reflect inflammatory alterations of MAT in CD and have found that certain features including visceral adipose tissue may inform risk of complicated disease behavior, risk for surgery, and postoperative outcomes. Additionally, emerging surgical data have suggested MAT may even be a therapeutic target to mitigate postoperative recurrence of CD. However, the current studies have variable results, reduced sample sizes, and methodological limitations that preclude incorporating the radiologic and surgical findings into clinical practice. Nonetheless, the results are promising and potentially have important implications for the medical and surgical management of CD, which merits that additional studies are warranted. Thus, we have reviewed the available literature on the medical and surgical implications of MAT in CD to summarize our current understanding and identify gaps in knowledge to inform future investigations.

Ileocolic Resection for Crohn Disease: The Influence of Different Surgical Techniques on Perioperative Outcomes, Recurrence Rates, and Endoscopic Surveillance

Ileocolic resection (ICR) is the most common surgical procedure in Crohn disease (CD). There are many surgical techniques for performing ICRs and subsequent anastomoses. Recurrence of CD after ICR is common, often clinically silent, and thus requires monitoring including periodic use of endoscopy to detect early active disease. There is emerging evidence that surgical approaches may influence CD recurrence. This review explores the various surgical considerations, the data behind each decision, and how these techniques influence subsequent endoscopic surveillance.

Does microscopic involvement of the surgical margins after ileocecectomy in Crohn's patients predict early recurrence?

OBJECTIVE

The primary aim of this study was to determine whether the microscopic presence of Crohn's disease (CD) in the resected specimen margins in patients undergoing ileocecectomy predicts disease recurrence. The secondary aim was to identify other risk factors which can predict recurrence.

METHODS

All CD patients who underwent ileocecectomy in a single colorectal unit between 2000 and 2015 were retrospectively evaluated. The diagnosis of CD and margin involvement status were retrieved from pathology reports. Recurrence was determined according to medical records or via a telephone questionnaire. Demographic, clinical, and surgical parameters were compared between patients with and without histopathologic evidence of CD in the resected margins.

RESULTS

A total of 202 CD patients were included, 49 with and 153 without evidence of microscopic involvement in the resected margins. The main demographic characteristics, surgical approach and procedure, and postoperative course, including medical treatment, clinical or endoscopic recurrence, and reoperation rates, were similar for both groups. Patients who were operated laparoscopically (n=58, p 0.016), conversion from laparoscopic to open (n=25, p 0.016), stapled anastomosis (n=150, p 0.004), when stricturoplasty was required (n=12, p 0.046), and those with perianal disease (n=32, p 0.045) had shorter time to recurrence. Male gender had increased hazard ratio (n=106, HR 1.38) for reoperation, but not significantly (p=0.058).

CONCLUSIONS

The presence of microscopic CD at the resected specimen margins was not associated with the risk of disease recurrence. Other demographic, clinical, and technical features that did correlate with early recurrence were identified. These results support a conservative approach to the extent of resection in CD patients undergoing ileocecectomy.

TRIAL REGISTRATION

Not relevant.

Post-surgical recurrence of Crohn's disease: Situational analysis and future prospects

Surgery retains a major role in the treatment of Crohn's disease, and the prevention of post-operative recurrence is an essential issue. In fact, despite the increasing use of biotherapies, almost all of the patients who undergo surgery will present with a recurrence, initially endoscopic and then clinical, eventually leading to a second intervention in 15 to 20% of cases. Certain risk factors for recurrence such as smoking, repeated and/or extensive resections, anoperineal involvement, myenteric plexitis, epithelioid granulomas, penetrating disease behaviour and lack of post-operative prophylactic treatment have been well established. Currently, measures to prevent post-operative recurrence are based mainly on smoking cessation in all patients and the prescription of anti-TNFα medications for patients with a high risk of recurrence (at least two risk factors for recurrence). However, new surgical techniques have recently been described which could modify post-operative prevention strategies. Kono's lateral anti-mesenteric anastomosis could significantly reduce clinical and endoscopic recurrence compared to conventional anastomosis techniques. Long latero-lateral isoperistaltic stricturoplasties have been shown to be feasible and are associated with a low rate of long-term symptomatic recurrence requiring surgery. In a preliminary series, intestinal resections with extensive mesenteric resection reduced the rate of recurrence in comparison with patients operated on conventionally (3% vs. 40% at five years). If the results of these new surgical techniques are confirmed, the indications for post-operative immunomodulatory treatments could be downgraded in patients currently considered to be at high risk of recurrence.

Meta-analysis of Histological Margin Positivity in the Prediction of Recurrence After Crohn's Resection

BACKGROUND

Despite significant advances in the medical management of Crohn's disease, many patients will require intestinal resection during their lifetime. It is disappointing that many will also develop disease recurrence.

OBJECTIVES

The current study utilizes meta-analytical techniques to determine the effect of positive histological margins at the time of index resection on disease recurrence.

DATA SOURCES

Embase, Medline, PubMed, PubMed Central, and Cochrane databases were searched using a Boolean search algorithm for articles published up to August 2017.

STUDY SELECTION

Meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

MAIN OUTCOME MEASURES

Databases were searched for studies reporting the outcomes for patients with Crohn's disease undergoing primary resection that correlated resection margin status with disease recurrence. Results were reported as pooled ORs with 95% CI.

RESULTS

A total of 176 citations were reviewed; 18 studies comprising 1833 patients were ultimately included in the analysis, with a mean rate of histopathological margin positivity of 41.7 ± 17.4% and a pooled mean follow-up of 69 ± 39 months. Histopathological margin positivity was associated with a higher rate of overall recurrence (OR, 1.7; 95% CI, 1.3-2.1; p < 0.001), clinical recurrence (OR, 1.7; 95% CI, 1.0-2.8; p = 0.04), and anastomotic recurrence (OR, 1.6; 95% CI, 1.0-2.3; p = 0.03). In studies reporting plexitis specifically at the resection margin, there was an increase in recurrence (OR, 2.3; 95% CI, 1.1-4.9; p = 0.02).

LIMITATIONS

The definitions of histological margin positivity and postoperative recurrence vary between the studies and follow-up durations vary.

CONCLUSIONS

The presence of involved histological margins at the time of index resection in Crohn's disease is associated with recurrence, and plexitis shows promise as a marker of more aggressive disease. Further studies with homogeneity of histopathological and recurrence reporting are required.

Inclusion of the Mesentery in Ileocolic Resection for Crohn's Disease is Associated With Reduced Surgical Recurrence

BACKGROUND AND AIMS

Inclusion of the mesentery during resection for colorectal cancer is associated with improved outcomes but has yet to be evaluated in Crohn's disease. This study aimed to determine the rate of surgical recurrence after inclusion of mesentery during ileocolic resection for Crohn's disease.

METHODS

Surgical recurrence rates were compared between two cohorts. Cohort A [n = 30] underwent conventional ileocolic resection where the mesentery was divided flush with the intestine. Cohort B [n = 34] underwent resection which included excision of the mesentery. The relationship between mesenteric disease severity and surgical recurrence was determined in a separate cohort [n = 94]. A mesenteric disease activity index was developed to quantify disease severity. This was correlated with the Crohn's disease activity index and the fibrocyte percentage in circulating white cells.

RESULTS

Cumulative reoperation rates were 40% and 2.9% in cohorts A and B [P = 0.003], respectively. Surgical technique was an independent determinant of outcome [P = 0.007]. Length of resected intestine was shorter in cohort B, whilst lymph node yield was higher [12.25 ± 13 versus 2.4 ± 2.9, P = 0.002]. Advanced mesenteric disease predicted increased surgical recurrence [Hazard Ratio 4.7, 95% Confidence Interval: 1.71-13.01, P = 0.003]. The mesenteric disease activity index correlated with the mucosal disease activity index [r = 0.76, p < 0.0001] and the Crohn's disease activity index [r = 0.70, p < 0.0001]. The mesenteric disease activity index was significantly worse in smokers and correlated with increases in circulating fibrocytes.

CONCLUSIONS

Inclusion of mesentery in ileocolic resection for Crohn's disease is associated with reduced recurrence requiring reoperation.

Stapled side-to-side anastomosis might be benefit in intestinal resection for Crohn's disease: A systematic review and network meta-analysis

BACKGROUND AND AIM

Intestinal anastomosis is an essential step in the intestinal resection in patients with Crohn's disease (CD). Anastomotic configuration such as handsewn end-to-end anastomosis (HEEA), stapled side-to-side anastomosis (SSSA) and so on may be a predictor of prognosis for postoperative CD patients. However, the association between anastomotic types and surgical outcomes are controversial. The aim of this review is to identify the optimal anastomosis for intestinal resection in patients with CD.

METHODS

Clinical trials comparing anastomosis after intestinal resection in patients with CD were searched in the database of MEDLINE, EMBASE, and the Cochrane Library. Outcomes such as postoperative hospital stay, complications, mortality, recurrence, and reoperation were evaluated. Pairwise treatment effects were estimated through a random-effects network meta-analysis based on the frequency framework by using the STATA software and reported as the estimated summary effect for each comparison between the 2 treatments in the network with a 95% credible interval.

RESULTS

A total of 1113 patients in 11 trials were included. In pair-wise comparisons between groups, for overall postoperative complications, SSSA showed a more probability of superiority to HEEA; for complications other than anastomotic leak, anastomotic leak, wound infection, postoperative hospital stay and mortality, there were no significant difference between groups; for clinical recurrence, SSSA showed a more probability of superiority to HEEA; for reoperation, SSSA showed a more probability of superiority to HEEA. The number of eligible randomized controlled trails (RCTs) was small, and more than half of the included trials were retrospective studies; selection bias may lead to a less power in this assessment; follow-up time between different groups was different, which may possibly have affected the interpretation of the analysis of long-term outcome.

CONCLUSION

By comprehensive analyzing all the postoperative outcomes, SSSA appeared to be the optimal anastomotic strategy after intestinal resection for patients with CD.

Sweet Sixteen: The Prospective Clinical Trials of John L. Cameron, MD-The Clinician-Scientist: From Alternate-allocation to Randomized Controlled Trials

: The era of randomized controlled trials was ushered in by the British epidemiologist-statistician Austin Bradford Hill, with his work on the use of streptomycin in patients with tuberculosis. John L. Cameron, can be linked to 16 prospective clinical trials over his career thus far, starting with alternate-allocation trials and transitioning to prospective, randomized, placebo-controlled trials. These trials studied various topics in surgery-from pancreatitis to surgical site infections, to drain trials, a trial in Crohn disease and multiple trials in pancreatic surgery and cancer. Herein are described the "sweet sixteen" prospective clinical trials of Dr Cameron.

Rates and Predictors of Endoscopic and Clinical Recurrence After Primary Ileocolic Resection for Crohn's Disease

BACKGROUND AND AIMS

The utility of postoperative medical prophylaxis (POMP) and the treatment of mild endoscopic recurrence remain controversial.

METHODS

This study is a retrospective review of patients undergoing a primary ileocolic resection for CD at a single academic center. Endoscopic recurrence (ER) was defined using the Rutgeerts score (RS), and clinical recurrence (CR) was defined as symptoms of CD with endoscopic or radiologic evidence of neo-terminal ileal disease.

RESULTS

There were 171 patients who met inclusion criteria. The cumulative probability of ER (RS ≥ i-1) at 1, 2, and 5 years was 29, 51, and 77 %, respectively. The only independent predictors of ER were the absence of POMP (HR 1.50; P = 0.03) and penetrating disease behavior (HR 1.50; P = 0.05). The cumulative probability of CR at 1, 2, and 5 years was 8, 13, and 27 %, respectively. There was a higher rate of clinical recurrence in patients with RS-2 compared to RS-1 on the initial postoperative endoscopy (HR 2.50; P = 0.02). In 11 patients not exposed to POMP with i-1 on initial endoscopy, only 2 patients (18 %) progressed endoscopically during the study period while 5 patients (45 %) regressed to i-0 on subsequent endoscopy without treatment.

CONCLUSIONS

Postoperative medical prophylaxis decreased the likelihood of ER while certain phenotypes of CD appear to increase the risk of developing ER and CR. There may be a role for watchful waiting in patients with mild endoscopic recurrence on the initial postoperative endoscopy.

The mesentery in Crohn's disease: friend or foe?

PURPOSE OF REVIEW

This article assesses the role of the mesentery in Crohn's disease.

RECENT FINDINGS

The mesentery is centrally positioned both anatomically and physiologically. Overlapping mesenteric and submucosal mesenchymal contributions are important in the pathobiology of Crohn's disease. Mesenteric contributions explain the topographic distribution of Crohn's disease in general and mucosal disease in particular. Operative strategies that are mesenteric based (i.e. mesocolic excision) may reduce rates of postoperative recurrence.

SUMMARY

The net effect of mesenteric events in Crohn's disease is pathologic. This can be targeted by operative means.

VIDEO ABSTRACT

http://links.lww.com/COG/A18.

Association between specific mucosa-associated microbiota in Crohn's disease at the time of resection and subsequent disease recurrence: a pilot study

BACKGROUND AND AIM

Crohn's disease pathogenesis involves alterations in the gut microbiota. We characterized the mucosa-associated microbiota at the time of surgical resection and 6 months later to identify bacterial profiles associated with recurrence and remission.

METHODS

Tissue samples were collected from surgical resection specimens in 12 Crohn's disease patients, and at 6 months postoperative colonoscopy from the neoterminal ileum and anastomosis. Endoscopic recurrence was assessed using the Rutgeerts score. Microbiota was characterized using microarray and 454 pyrosequencing. Longitudinal comparisons were made within patients, and cross-sectional comparisons made with colonoscopic biopsies from the terminal ileum and cecum of 10 healthy subjects.

RESULTS

Microbiota of healthy subjects had high diversity and was dominated by the Firmicutes, Bacteroidetes, and Proteobacteria phyla. Biodiversity was lower in Crohn's disease patients at the time of surgery, increased after surgery, but still differed from healthy subjects. Crohn's disease patients with recurrent disease retained a microbiota favoring proteolytic-fueled fermentation and lactic acid-producing bacteria, including Enterococcus and Veillonella spp., while those maintaining remission demonstrated predominant saccharolytic Bacteroides, Prevotella, and Parabacteroides spp., and saccharolytic, butyrate-producing Firmicutes.

CONCLUSION

In Crohn's disease, the mucosa-associated microbiota diversity is reduced at the time of surgery, but also differs between patients with different clinical outcomes at 6 months. These findings may provide prognostic information at the time of surgery, allowing identification of patients at increased risk of recurrence, and provide basis for a more targeted approach for therapeutic interventions after surgery.

Stapled side-to-side anastomosis might be better than handsewn end-to-end anastomosis in ileocolic resection for Crohn's disease: a meta-analysis

BACKGROUND

Ileocolic anastomosis is an essential step in the treatment to restore continuity of the gastrointestinal tract following ileocolic resection in patients with Crohn's disease (CD). However, the association between anastomotic type and surgical outcome is controversial.

AIMS

The aim of this meta-analysis is to compare surgical outcomes between stapled side-to-side anastomosis (SSSA) and handsewn end-to-end anastomosis (HEEA) after ileocolic resection in patients with CD.

METHODS

Studies comparing SSSA with HEEA after ileocolic resection in patients with CD were identified in PubMed and EMBASE. Outcomes such as complication, recurrence, and re-operation were evaluated. Eight studies (three randomized controlled trials, one prospective non-randomized trial, and four non-randomized retrospective trials) comparing SSSA (396 cases) and HEEA (425 cases) were included.

RESULTS

As compared with HEEA, SSSA was superior in terms of overall postoperative complications [odds ratio (OR), 0.54; 95 % confidence interval (CI) 0.32-0.93], anastomotic leak (OR 0.45; 95 % CI 0.20-1.00), recurrence (OR 0.20; 95 % CI 0.07-0.55), and re-operation for recurrence (OR 0.18; 95 % CI 0.07-0.45). Postoperative hospital stay, mortality, and complications other than anastomotic leak were comparable.

CONCLUSION

Based on the results of our meta-analysis, SSSA would appear to be the preferred procedure after ileocolic resection for CD, with reduced overall postoperative complications, especially anastomotic leak, and a decreased recurrence and re-operation rate.

Complications after end-to-end vs. side-to-side anastomosis in ileocecal Crohn's disease--early postoperative results from a randomized controlled multi-center trial (ISRCTN-45665492)

BACKGROUND

Recurrent Crohn's disease activity at the site of anastomosis after ileocecal resection is of great surgical importance. This prospective randomized multi-center trial with an estimated case number of 224 patients was initially planned to investigate whether stapled side-to-side anastomosis, compared to hand-sewn end-to-end anastomosis, results in a decreased recurrence of Crohn's disease following ileocolic resection (primary endpoint). The secondary endpoint was to focus on the early postoperative results comparing both surgical methods. The study was terminated early due to insufficient patient recruitment and because another large study investigated the same question, while our trial was ongoing.

METHODS AND STUDY DESIGN

Patients with stenosing ileitis terminalis in Crohn's disease who underwent an ileocolic resection were randomized to side-to-side or end-to-end anastomosis. Due to its early discontinuation, our study only investigated the secondary endpoints, the early postoperative results (complications: bleeding, wound infection, anastomotic leakage, first postoperative stool, duration of hospital stay).

RESULTS

From February 2006 until June 2010, 67 patients were enrolled in nine participating centers. The two treatment groups were comparable to their demographic and pre-operative data. BMI and Crohn's Disease Activity Index were 22.2 (± 4.47) and 200.5 (± 73.66), respectively, in the side-to-side group compared with 23.3 (± 4.99) and 219.6 (± 89.03) in the end-to-end group. The duration of surgery was 126.7 (± 42.8) min in the side-to-side anastomosis group and 137.4 (± 51.9) min in the end-to-end anastomosis group. Two patients in the end-to-end anastomosis group developed an anastomotic leakage (6.5%). Impaired wound healing was found in 13.9% of the side-to-side anastomosis group, while 6.5% of the end-to-end anastomosis group developed this complication. The duration of hospital stay was comparable in both groups with 9.9 (± 3.93) and 10.4 (± 3.26) days, respectively.

CONCLUSIONS

Because of the early discontinuation of the study, it is not possible to provide a statement about the perianastomotic recurrence rates regarding the primary endpoint. With regard to the early postoperative outcome, we observed no difference between the two types of anastomosis.

The evolving management of postoperative Crohn's disease

Two-thirds to three-quarters of Crohn's disease patients require intestinal surgery for medically refractory disease or complications. Surgery is not a cure and most patients develop recurrent Crohn's disease and require additional intestinal resections. There are a number of medications that have been investigated for preventing and treating recurrence. Risk factors for postoperative disease recurrence help guide the physician in determining the appropriate treatment strategy after Crohn's disease surgery. The approach to Crohn's disease treatment has evolved over the years. No longer should surgery be considered a failure of treatment, rather an important intervention to correct irreversible disease. In combination with a better understanding of postoperative medication strategies, patients with Crohn's disease may achieve longer term remission than previously realized. This review elucidates current understanding of the natural course of postoperative Crohn's disease, monitoring for recurrence, the risk factors for recurrence, and provides insight into an evolving new paradigm for postoperative Crohn's disease treatment.

Prevention of postoperative recurrence of Crohn's disease

BACKGROUND

Up to 75% of patients with Crohn's disease (CD) will have intestinal resection during their life. Most patients will, however, develop postoperative recurrence (endoscopic, clinical or surgical). Several medical and surgical strategies have been attempted to prevent postoperative recurrence. This review evaluates the efficacy of different drug regimens and surgical techniques in the prevention of clinical, endoscopic and surgical postoperative recurrence of CD.

METHODS

A literature search for randomized controlled trials on medical or surgical interventions was performed. The endpoints for efficacy were clinical, endoscopic and surgical recurrence. Meta-analyses were performed in case two or more RCTs evaluated the same drug or surgical technique.

RESULTS

Mesalamine is more effective in preventing clinical recurrence than placebo (P=0,012), as well as nitroimidazolic antibiotics at one year follow-up (P<0.001) and thiopurines (P=0.018). Nitroimidazolic antibiotics are also more effective than placebo in preventing endoscopic recurrence (P=0.037), as well as thiopurines (P=0.015) and infliximab (P=0.006). Budenoside, probiotics, Interleukin-10 nor any of the different surgical procedures showed any significant difference compared to placebo in postoperative recurrence rates of CD.

CONCLUSION

Among the different drug regimens and surgical techniques, only thiopurines and nitroimidazolic antibiotics are able to reduce postoperative clinical as well as endoscopic recurrence of CD. Mesalamine and infliximab also seem to be superior to placebo in preventing clinical recurrence and endoscopic recurrence, respectively. There is a paucity of trials evaluating long-term follow-up and prevention of surgical recurrence of CD.

The surgical options and management of intestinal Crohn's disease

Crohn's disease (CD) is a pan-gastrointestinal illness. It is notorious for recurrences which can develop in any segment of the gastrointestinal tract. There are many indications and surgical options for intestinal Crohn's disease . We discuss these options based on the current literature. It is important to note however, that operative treatment is based on the correct diagnosis, clinical presentation, sphincter function and patient motivation. Early and timely referral to a surgeon is paramount. The goals of continued medical therapy need to be clearly defined as do the criteria for referral to surgery.

Factors associated with operative recurrence early after resection for Crohn's disease

INTRODUCTION

Some Crohn's disease (CD) patients develop rapid disease recurrence requiring reoperation. Identification of factors associated with early operative recurrence of CD may help risk-stratify patients and prevent recurrence.

METHODS

Prospectively collected data of CD patients undergoing bowel resection for CD with unequivocal evidence of recurrence at reoperation were retrieved. Patients with earlier recurrence (less than median time of recurrence of study cohort) were compared with those who developed later recurrence (greater than median time of recurrence) for patient and disease characteristics and risk factors for recurrence. A multivariate logistic regression model was performed to identify factors associated with earlier operative recurrence.

RESULTS

Sixty-nine patients (45 female, 24 male) met the inclusion criteria. Median time to reoperation was 38 months (range, 3.3-236 months). One hundred six reoperations in the 69 patients were for abscess/fistula/perforation (n = 45), stricture/stenosis (n = 41), inflammation (n = 17), bleeding (n = 2), and dysplasia (n = 1). Factors associated with early rather than late reoperation included behavior of disease (stricturing, odds ratio (OR) 12.1; confidence interval (CI), 1.8-80.9; penetrating OR, 9.9; CI, 1.4-67.9 rather than nonstricturing nonpenetrating) and the development of postoperative complications at previous surgery (OR, 12.1; CI, 1.2-126.6).

CONCLUSION

Earlier recurrence of CD requiring reoperation is associated with specific disease and potentially modifiable operation-related factors such as postoperative complications, i.e., anastomotic leak or intraabdominal abscess. Strategies to reduce recurrence in such patients include the identification of factors that may reduce postoperative complications.

Crohn's disease: a surgeon's perspective

Crohn's disease (CD) is known for wide anatomic distribution, different presentations, life-threatening complications, and multiple modalities of management. Its multiple implications are still unaddressed. Since all the patients do not show a good response to medical modalities of treatment, a significant percentage of these patients are referred to the surgeon for the palliation of complications or for the ultimate curative treatment. Since most surgeons come across such patients only rarely, it is sometimes difficult for them to choose the appropriate procedure at the time of need. Moreover, the various surgical modalities available for the different presentations and complications of the disease have not been adequately discussed. The aim of this review is to offer insight and a detailed account of the management of CD from a surgical perspective. This review offers an overview of the various surgical options available, their utility in context, and an approach to various scenarios of complicated CD.

Adjunctive antibiotic therapy with rifaximin may help reduce Crohn's disease activity

AIMS

Enteric bacteria are thought to contribute to the pathogenesis of Crohn's disease, and antibiotics may be an effective therapy. This study examines the efficacy of the nonsystemic (<0.4% absorbed) antibiotic rifaximin for inducing remission in patients with Crohn's disease.

METHODS

Data from charts of patients with Crohn's disease who received rifaximin between 2001 and 2005 and had a Crohn's disease activity index score > or =220 at the time of rifaximin initiation were analyzed. The use of concomitant medications (e.g., steroids, anti-inflammatory agents) was allowed.

RESULTS

In the 68 patient charts analyzed, the median duration of rifaximin treatment was 16.6 weeks, and the majority of patients (94%) received rifaximin 600 mg/day. Eighteen patients (26%) received rifaximin monotherapy, and 31 patients (46%) received concomitant steroids. The median baseline Crohn's disease activity index score at the time of rifaximin initiation was 265 (range, 220-460), and the mean duration of Crohn's disease was 17 years (range, 1-50 years). Crohn's disease remission occurred in 65% of patients. A 70% remission rate was achieved in patients who did not receive steroids, versus 58% in patients who received steroids. Clinical improvements continued 4 months after rifaximin initiation. Remission was achieved in 67% of patients who received rifaximin monotherapy.

CONCLUSIONS

Rifaximin therapy was associated with clinical improvement in patients with Crohn's disease and may be a useful treatment option to consider for inducing and maintaining remission.

Postoperative management of Crohn disease

Crohn disease often recurs after surgical resection. Despite extensive research in the prevention of postoperative Crohn disease, optimal management strategies have yet to be defined. Risk of disease recurrence needs to be carefully balanced against potential risks associated with treatment. Patients with low risk of postoperative recurrence may not require medication, whereas those at moderate risk may benefit from antibiotics or immunomodulators. Those at highest risk of recurrence may benefit from biologic therapy for maintenance of surgical remission. Postoperative colonoscopy within 1 year of resective surgery is important for identification of disease recurrence and modification of medications.

Postoperative management of crohn disease

Crohn disease often recurs after surgical resection. Despite extensive research in the prevention of postoperative Crohn disease, optimal management strategies have yet to be defined. Risk of disease recurrence needs to be carefully balanced against potential risks associated with treatment. Patients with low risk of postoperative recurrence may not require medication, whereas those at moderate risk may benefit from antibiotics or immunomodulators. Those at highest risk of recurrence may benefit from biologic therapy for maintenance of surgical remission. Postoperative colonoscopy within 1 year of resective surgery is important for identification of disease recurrence and modification of medications.

Interventions for prevention of post-operative recurrence of Crohn's disease

BACKGROUND

Recurrence of Crohn's disease is common after intestinal resection. A number of agents have been studied in controlled trials with the goal of reducing the risk of endoscopic or clinical recurrence of Crohn's disease following surgery.

OBJECTIVES

To undertake a systematic review of the use of medical therapies for the prevention of post-operative recurrence of Crohn's disease

SEARCH STRATEGY

MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify relevant studies. References from selected papers and abstracts from Digestive Disease Week were also searched.

SELECTION CRITERIA

Randomised controlled trials that compared medical therapy to placebo or other medical agents for the prevention of recurrence of intestinal Crohn's disease were selected for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors reviewed all abstracts containing search terms, and those meeting inclusion criteria were selected for full data abstraction. Dichotomous data were summarised using relative risk and 95% confidence intervals. A fixed-effects model was used, and sensitivity analysis performed.

MAIN RESULTS

Twenty-three studies were identified for inclusion. Probiotics were not superior to placebo for any outcome measured. The use of nitroimidazole antibiotics appeared to reduce the risk of clinical (RR 0.23; 95%CI 0.09 to 0.57, NNT=4) and endoscopic (RR 0.44; 95%CI 0.26 to 0.74, NNT = 4) recurrence relative to placebo. However, these agents were associated with higher risk of serious adverse events (RR 2.39, 95% CI 1.5 to 3.7). Mesalamine therapy was associated with a significantly reduced risk of clinical recurrence (RR 0.76; 95% CI 0.62 to 0.94, NNT = 12), and severe endoscopic recurrence (RR 0.50; 95% CI 0.29 to 0.84, NNT = 8) when compared to placebo. Azathioprine/6MP was also associated with a significantly reduced risk of clinical recurrence (RR 0.59; 95% CI 0.38 to 0.92, NNT = 7), and severe endoscopic recurrence (RR 0.64; 95% CI 0.44 to 0.92, NNT = 4), when compared to placebo. Neither agent had a higher risk than placebo of serious adverse events. When compared to azathioprine/6MP, mesalamine was associated with a higher risk of any endoscopic recurrence (RR 1.45, 95% CI 1.03 to 2.06), but a lower risk of serious adverse events (RR 0.51; 95% CI 0.30 to 0.89). There was no significant difference between mesalamine and azathioprine/6MP for any other outcome.

AUTHORS' CONCLUSIONS

There are insufficient randomised controlled trials of infliximab, budesonide, tenovil and interleukin-10 to draw conclusions. Nitro-imidazole antibiotics, mesalamine and immunosuppressive therapy with azathioprine/6-MP or infliximab all appear to be superior to placebo for the prevention of post-operative recurrence of Crohn's disease. The cost, toxicity and tolerability of these approaches require careful consideration to determine the optimal approach for post-operative prophylaxis.

Disordered macrophage cytokine secretion underlies impaired acute inflammation and bacterial clearance in Crohn's disease

The cause of Crohn's disease (CD) remains poorly understood. Counterintuitively, these patients possess an impaired acute inflammatory response, which could result in delayed clearance of bacteria penetrating the lining of the bowel and predispose to granuloma formation and chronicity. We tested this hypothesis in human subjects by monitoring responses to killed Escherichia coli injected subcutaneously into the forearm. Accumulation of (111)In-labeled neutrophils at these sites and clearance of (32)P-labeled bacteria from them were markedly impaired in CD. Locally increased blood flow and bacterial clearance were dependent on the numbers of bacteria injected. Secretion of proinflammatory cytokines by CD macrophages was grossly impaired in response to E. coli or specific Toll-like receptor agonists. Despite normal levels and stability of cytokine messenger RNA, intracellular levels of tumor necrosis factor (TNF) were abnormally low in CD macrophages. Coupled with reduced secretion, these findings indicate accelerated intracellular breakdown. Differential transcription profiles identified disease-specific genes, notably including those encoding proteins involved in vesicle trafficking. Intracellular destruction of TNF was decreased by inhibitors of lysosomal function. Together, our findings suggest that in CD macrophages, an abnormal proportion of cytokines are routed to lysosomes and degraded rather than being released through the normal secretory pathway.

Postoperative Crohn's disease: prevention and treatment

Crohn's disease is a chronic, relapsing-remitting inflammatory disease of the intestinal tract that commonly requires surgical treatment. Unfortunately, the majority of patients will ultimately develop postoperative disease recurrence and require subsequent surgery. A number of medications have been researched for the maintenance of postoperative remission. Of these, few have demonstrated consistent efficacy. A recently published randomized, controlled trial indicated that infliximab is effective in the maintenance of postoperative remission.

Recurrence of Crohn's disease after ileocolic resection is not affected by anastomotic type: results of a multicenter, randomized, controlled trial

PURPOSE

This study attempts to determine whether stapled side-to-side anastomosis, compared with handsewn end-to-end anastomosis, results in decreased recurrence of Crohn's disease following ileocolic resection.

METHODS

Patients with Crohn's disease who underwent an ileocolic resection were randomized to side-to-side anastomosis or end-to-end anastomosis. Colonoscopy was performed at 12 months. The primary outcome was endoscopic recurrence, while the secondary outcome was symptomatic recurrence (defined as symptoms attributable to Crohn's disease and severe enough to warrant treatment, plus endoscopic disease recurrence).

RESULTS

One hundred and thirty-nine subjects were included in the efficacy analysis. After a mean follow-up of 11.9 months, the endoscopic recurrence rate was 42.5 percent in the end-to-end anastomosis group, compared with 37.9 percent in the side-to-side anastomosis group (-4.6 percent difference; 95 percent confidence interval -21.0 to 11.9 percent; P = 0.55). The symptomatic recurrence rate was 21.9 percent in the end-to-end anastomosis group, compared with 22.7 percent in the side-to-side anastomosis group (+0.8 percent difference; 95 percent confidence interval -13.2 to 15.3 percent; P = 0.92). In multivariate logistic regression analysis, previous resections were predictive of a higher risk of both endoscopic (odds ratio 1.78; 95 percent confidence interval 1.06 to 2.90; P = 0.028) and symptomatic (odds ratio 2.0; 95 percent confidence interval 1.14 to 3.60; P = 0.0016) recurrence. Compliance with postoperative maintenance therapy was predictive of a lower risk of symptomatic recurrence (odds ratio 0.13, 95 percent confidence interval 0.01 to 0.78; P = 0.021).

CONCLUSION

Recurrence rates are similar whether end-to-end anastomosis or side-to-side anastomosis is performed.

TGF-beta1 and IGF-1 and anastomotic recurrence of Crohn's disease after ileo-colonic resection

BACKGROUND

After bowel resection, Crohn's disease (CD) recurs frequently in the site of the anastomosis. Alteration of normal healing processes may play a role in this phenomenon. Transforming growth factor beta (TGF-beta) and insulin-like growth factor (IGF-1) are involved in wound healing mechanisms with pro-fibrogenic properties. The aim of this study was to assess the expression of TGF-beta1 and insulin-like growth factor 1 (IGF-1) in the different zones of the bowel wall to understand why side-to-side anastomosis are associated to a lower recurrence rate compared to end-to-end ones.

PATIENTS AND METHODS

Seventeen patients affected by CD who underwent ileo-colonic resection from 2004 to 2005 were enrolled in this study. Full-thickness tissue samples were obtained from the mesenteric, the lateral, and the anti-mesenteric sides of the macroscopically diseased and healthy ileum for each patient. TGF-beta1 and IGF-1 messenger RNAs (mRNAs) were quantified by real-time polymerase chain reaction. Myeloperoxidase activity and histological disease activity were assessed to quantify the ileal inflammation. Vimentin, desmin, and alpha-smooth muscle actin were stained with immunohistochemistry to assess the fibroblast, smooth muscle cell, and myofibroblasts populations. Comparisons and correlations were carried out with nonparametric tests.

RESULTS

In diseased ileum, TGF-beta1 mRNA transcripts in the antimesenteric side were significantly lower than those of the mesenteric side (p = 0.05), and a significant correlation between TGFbeta-1 levels in diseased bowel and the sampling site was observed (tau = 0.36, p = 0.03). On the contrary, neither the IGF-1 mRNA transcripts nor the distribution of fibroblast, smooth muscle cell, and myofibroblasts populations showed any relation with the sampling site.

CONCLUSION

TGF-beta1 mRNA expression was lower in the anti-mesenteric side of the diseased ileum, and this was consistent with the success of side-to-side anastomosis in preventing CD recurrence. Since high expression of TGF-beta1 was associated to early recurrence, it seems rationale to construct the anastomosis on the anti-mesenteric side of the bowel.

Management of postoperative Crohn's disease

Three-quarters of the patients with Crohn's disease (CD) require surgery involving a resection in the course of their disease. Even if all macroscopically involved bowel is removed, the disease usually recurs proximal to, and at, the anastomosis. This often leads to the recurrent need for treatment of active disease, complications, and reoperation. Ileocolonoscopy has an important place in the assessment of postoperative Crohn's recurrence. The limited available data regarding drug therapy in the postoperative setting suggest that optimal management should include identification of high-risk patients earlier and more widespread use of immunosuppressive therapy than was previously recommended, and colonoscopic monitoring. Such strategies to prevent recurrence then need to be prospectively evaluated. This article examines the evidence for medical prophylaxis of postoperative CD, and proposes a treatment strategy based on current evidence.

Long-term clinical results of ileocecal resection for Crohn's disease

BACKGROUND

The efficacy of biologic agents in Crohn's disease (CD) has led to proposals that they be introduced early in the disease (top-down treatment) with the aim of reducing corticosteroid dependency and surgical resection. However, the long-term use of biologic agents in limited CD may be difficult to justify. The aims were to assess outcomes for ileocecal resection in CD and evaluate its role in the current era.

METHODS

The study included 139 CD patients who underwent ileocecal resection between 1980 and 2000. Data were retrieved from a prospectively maintained database. Disease recurrence was defined as symptoms in addition to endoscopic or radiological evidence of disease activity. Severe disease recurrence was defined as a need for repeat resection surgery.

RESULTS

Seventy-two (52%) patients developed disease recurrence. Median (interquartile range) time to recurrence was 7.1 (5-10.6) years. Forty-nine (35%) patients required repeat resection surgery. Median (IQ range) time to repeat surgery was 7.2 (4.9-10.8) years. The presence of granulomas was associated with disease recurrence (P = 0.03) and repeat resection surgery (P = 0.01).

CONCLUSIONS

Long-term outcomes for ileocecal resection in CD are excellent with 48% of patients remaining symptom-free and only 35% requiring repeat resection surgery at 10 years. This should be borne in mind when considering biologic therapy.

A meta-analysis comparing conventional end-to-end anastomosis vs. other anastomotic configurations after resection in Crohn's disease

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.

Review article: recurrence of Crohn's disease after surgery - the need for treatment of new lesions

Crohn's recurrence is the appearance of objective signs - defined radiologically, endoscopically or pathologically - of Crohn's disease in the bowel of a patient who has previously had a resection of all macroscopically diseased tissue. New lesions can be visualized endoscopically within weeks to months after ileal resection and ileocolonic anastomosis in the neoterminal ileum. The evolution of these lesions mimics the natural history of ileal Crohn's disease at the onset. If we are able to prevent recurrence of early lesions, we will probably interrupt the natural course of the disease. The drugs tested to date include different 5-aminosalicylate formulations, nitro-imidazole antibiotics, steroids and azathioprine. None of these therapies has convincingly been shown to prevent recurrent lesions. Metronidazole and ornidazole are effective, but cannot be used in the long-term because of side effects. Since there is a lag time of months to years between the development of recurrent lesions in the bowel and the recurrence of symptoms, we recommend performing imaging of the bowel 6 months after the operation to assess the severity of recurrence, and basing the further treatment strategy on this assessment.

Inflammatory bowel disease: the view of the surgeon

Despite advances in medical therapy, surgery is required in approximately 30-40% of patients with ulcerative colitis (UC) and 70-80% of patients with Crohn's disease (CD) at some point during their lifetime. For patients with UC, surgery may be curative, whereas recurrence of CD following surgery is common due to the potentially pan-enteric distribution of the disease. As a result, the indications and surgical management of the disease may be quite different. For UC, the surgeon is involved in the identification of new cases, management of severe disease, recognition of dysplasia and restorative proctocolectomy. Most of the advances in surgery for UC have been in novel techniques relating to the ileal pouch-anal anastomosis, which can now be performed safely for UC with a 10% pouch failure rate long term. For CD, the surgeon is involved in the management of small bowel and ileo-colonic disease, Crohn's colitis and perianal disease. Advances in the surgical management of CD include strictureplasty for extensive small bowel disease, laparoscopic ileo-caecal resection and a combined medical and surgical approach to perianal disease. For both CD and UC close liaison between the gastroenterologist and colorectal surgeon is essential.

The value of myenteric plexitis to predict early postoperative Crohn's disease recurrence

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.

Postoperative Crohn's disease

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.

Azatioprina y mesalazina en la prevención de la recurrencia posquirúrgica en la enfermedad de Crohn: estudio retrospectivo

OBJECTIVES

Surgical resection is still a mainstay of the treatment of Crohn's disease (CD). However, recurrence is the rule. The aim of the present study was to evaluate CD recurrence in a series of patients who underwent surgical resection with subsequent treatment with azathioprine (AZA) or mesalazine (5-ASA) and to identify the factors associated with recurrence.

METHODS

The medical records of patients with CD who underwent bowel resection during a 4-year period were reviewed. Only patients who received AZA or 5-ASA as prophylaxis for recurrence were included.

RESULTS

Thirty-three patients treated with AZA and 16 treated with 5-ASA were included. Endoscopic recurrence was found in 8.6% of the AZA group and in 87.5% of the 5-ASA group (p <0.001). Clinical recurrence occurred in 31.2% of patients in the 5-ASA group and in none in the AZA group (p=0.004). The accumulated probability of both clinical and endoscopic recurrence was significantly lower in the AZA group (p=0.0025 and p=0.005, respectively). Factors associated with a greater risk of endoscopic recurrence were termino-terminal anastomosis and 5-ASA treatment. The only factor associated with clinical recurrence was 5-ASA treatment.

CONCLUSION

AZA seems to be more effective than 5-ASA in the prevention of postsurgical endoscopic recurrence of CD. Prospective studies with long-term follow-up are required to establish the true utility of AZA in the prophylaxis of CD recurrence.

Medical treatment of Crohn's disease

Crohn's disease is not medically (and is rarely surgically) curable. Patients do, however, live a normal life span. The goal of therapy is to optimize the quality of life, minimize disease activity and disease-related complications, and avoid therapeutic toxicity.

Wide-lumen stapled anastomosis vs. conventional end-to-end anastomosis in the treatment of Crohn's disease

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.

Prevention of postoperative recurrence in Crohn's disease

Postoperative recurrence of Crohn's disease is often inevitable. Certain risk factors such as smoking, young age, and a perforating disease behavior have been identified. Patients with an enhanced risk profile should be treated with mesalamine or with azathioprine, the latter of which has higher success rates. An endoscopic evaluation of the neoterminal ileum performed 6 to 12 months after surgery provides important prognostic information regarding the further clinical course of the disease and can be used as a guide to optimize medical therapy.

Postoperative recurrence of Crohn's disease: pathophysiology and prevention

Postoperative recurrence of Crohn's disease is often inevitable. Certain risk factors such as smoking, young age, and a perforating disease behavior have been identified. Patients running an enhanced risk should be treated with mesalamine or, with higher success rates, with azathioprine. An endoscopic evaluation of the neoterminal ileum 6 to 12 months after surgery provides relevant information predicting the further clinical course and can be used as a guide to adjust medical therapy.

Postoperative outcome of Crohn's disease in 30 children

BACKGROUND

Thirty children operated on for Crohn's disease (CD) were reviewed (1975-1994). The aim of the study was to assess their postoperative outcome.

PATIENTS

19 boys and 11 girls, aged 15.3 (2) years (range 11.3-20) at surgery were studied.

RESULTS

Surgical indications were acute complications of CD and chronic intestinal illness. Six months after surgery, 11 of 12 patients had been weaned off steroids, and 22 of 23 patients were weaned off nutritional support; 17 patients without recurrence had a mean (SD) weight gain of 2.1 (8) kg and a height gain of 3.36 (3) cm. During 3.1 (2.7) years follow up, 12 patients (40%) had a recurrence of the disease after 19.4 (14) months (means (SD)): supra-anastomotic recurrence (six), severe perianal disease (two), and chronic illness (four). Six of 14 patients who were treated with mesalazine (13) or azathioprine (one) had recurrences. The postoperative recurrence rate was 50% at two years.

CONCLUSION

Surgical treatment modifies the immediate outcome of severe or complicated CD, but does not prevent recurrence, despite localised resection or prophylactic postoperative treatment. Extension of the disease before surgery seems to be a major risk factor for postoperative recurrence in children.

Comparison of primary and reoperative surgery in patients with Crohns disease

OBJECTIVE

This study was performed to determine the clinical results of patients with Crohns disease who require surgical resection. The outcome of patients undergoing initial surgery was compared with those having reoperation.

METHODS

One hundred sixty-four patients undergoing intestinal resection for Crohns disease at The Mount Sinai Hospital from 1976 to 1989 were studied prospectively. The mean duration of follow-up was 72 months.

RESULTS

Ninety patients (55%) underwent initial intestinal resection whereas 74 patients (45%) underwent reoperation for recurrent disease. Patients undergoing reoperation were older (33.4 vs. 38.7 years), had longer durations of disease (8.7 vs. 15.2 years), had shorter resections (60 vs. 46 cm), and were more likely to require ileostomy. Forty-seven percent of the patients with multiple previous resections required an ileostomy. This group also received a mean of 2.3 U blood in the perioperative period and showed a trend to increased symptomatic recurrence (49% vs. 71% at 5 years).

CONCLUSIONS

Patients with Crohns disease undergoing first and second reoperation have outcomes similar to those in patients undergoing primary resection. Patients requiring multiple reoperations are more likely to require blood transfusions and permanent ileostomy and to show a greater trend to early symptomatic recurrence.