Long-term outcome after intestinal resection for Crohn's disease

Objective. To assess the need for intestinal repeat resection for recurrence of Crohn's disease in patients observed for more than 20 years after the first resection. Material and methods. Data were gathered retrospectively from the medical records of 53 (28 F) consecutive patients with Crohn's disease from May 1954 to December 2002. Median age at first intestinal resection was 24.5 (range 13–65) years, and median observation time thereafter was 26.5 (20.1–48.6) years. Disease location and behaviour were defined according to the Vienna classification. Results. The 53 patients had an average 2.7 and a median 2 intestinal resections. Out of 144 intestinal resections (77.1%) 111 were performed during the first three operations; no alterations in distribution of ileal, ileocolic and colic resections were found. From the first to the third operation there was an increase in penetrating disease from 15% to 39% (p=0.046) concomitant with a decrease in stricturing disease from 72% to 44% (p=0.048) of the patients. There was also a corresponding decrease in ileocolic disease from 45% to 5% (p=0.003) and a tendency towards an increase in ileal disease from 38% to 67%. One patient died (1.8%) from rectosigmoid perforation after the third resectional operation. Six patients needed reoperation (11.3%) for ileus, anastomotic bleeding, rectosigmoidal perforation and abdominal pain. Thirty-four patients (64.2%) needed intestinal repeat resection (median 8.3 years) during 25.3 years after the first repeat resection. Conclusions. This study indicates a diminution of Crohn's disease activity with time, as demonstrated by no need for intestinal repeat resection more than 25 years after the first resection.     

Laparoscopic-assisted intestinal resection for Crohn's disease

PURPOSE: The inflammatory process associated with Crohn's disease often makes dissection difficult, even in open surgery. This study was undertaken to determine if dissection and resection could be performed laparoscopically and whether it would benefit this group of patients. METHODS: Between November 1992 and November 1994, laparoscopic-assisted intestinal resection was attempted in 18 patients with Crohn's disease and was successfully completed in 14. One patient had ileal disease, requiring ileal resection with ileoileal anastomosis. The remainder had disease requiring ileocolic resections. Muscle-splitting incisions averaging 5 cm in length were made to facilitate removal of specimens. RESULTS: Commencement of oral alimentation was possible at an average of 3.6 (range, 1–7) days postoperatively. Discharge occurred at an average of 6.6 (range, 4–9) postoperative days. In comparison, 14 patients operated on by the authors for the same disease in the open manner during the past six months stayed an average of 8.5 (range, 5–14) postoperative days. Postoperative complications were minimal. CONCLUSIONS: On the basis of this initial study, it appears that laparoscopic-assisted intestinal resection can be readily performed in patients with Crohn's disease. In our early experience, we have found that laparoscopic mobilization and resection may be difficult or impossible in patients with large fixed masses, multiple complex fistulas, or recurrent Crohn's disease. Extraction incisions are frequently so large in these patients that they do not derive the same benefits from laparoscopic surgery that are enjoyed by patients without these findings. Most patients having laparoscopic resections eat earlier, may require fewer narcotics, and are able to be discharged from the hospital an average of two days earlier than patients operated on in an open manner. In addition, it appears that laparoscopic-assisted intestinal resection results in a shorter, easier convalescence and an earlier return to full activity.     

Long-term outcome after extensive intestinal resection for chronic radiation enteritis

IntroductionManagement of chronic radiation enteritis is often controversial, particularly due to the risk of short bowel syndrome.MethodsOne hundred and seven chronic radiation enteritis patients with short bowel syndrome were studied retrospectively between 1980 and 2009. Survival and home parenteral nutrition dependence rates were evaluated with univariate and multivariate analysis.ResultsThe survival probabilities were 93%, 67% and 44.5% at 1, 5 and 10 years, respectively. On multivariate analysis, survival was significantly decreased with residual neoplastic disease (HR = 0.21 [0.11–0.38], p < 0.001), an American Society of Anesthesiologists score >3 (HR = 0.38 [0.20–0.73], p = 0.004) and an age of chronic radiation enteritis diagnosis >60 years (HR = 0.45 [0.22–0.89], p = 0.02). The actuarial home parenteral nutrition dependence probabilities were 66%, 55% and 43% at 1, 2 and 3 years, respectively. On multivariate analysis, this dependence was significantly decreased when there was a residual small bowel length >100 cm (HR = 0.35 [0.18–0.68], p = 0.002), adaptive hyperphagia (HR = 0.39 [0.17–0.87], p = 0.02) and the absence of a definitive stoma (HR = 0.48 [0.27–0.84], p = 0.01).ConclusionThe survival of patients with diffuse chronic radiation enteritis after extensive intestinal resection was good and was mainly influenced by underlying comorbidities. Almost two-thirds of patients were able to be weaned off home parenteral nutrition.     

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.     

Long-term outcome of Crohn's disease following corticosteroid-induced remission

INTRODUCTION: Corticosteroids are the gold standard in the treatment of moderate to severe Crohn's disease but are often associated with severe and potentially dangerous side effects. Despite an initial clinical response many patients become steroid dependent or require further steroid courses in the long term. The aim of the present study was to assess the probability of the need for further steroid treatment in Crohn's disease patients following steroid-induced remission and to establish if clinical variables can predict further steroid needs. PATIENTS AND All METHODS: patients at their first steroid course and with corticosteroid-induced remission, defined as a Crohn's Disease Activity Index (CDAI) <150, 4 wk after steroid weaning, were studied and observed at follow-up for 12 months. The main outcome was clinical relapse requiring further steroid treatment. Statistical analysis was performed using the Kaplan-Meier method and multivariable Cox proportional hazard regression model taking into consideration gender, age at diagnosis, disease location and behavior, smoking habits, CDAI score before steroid treatment, and C reactive protein values at steroid weaning, as covariates. RESULTS: A total of 77 patients with steroid-induced remission were included. One-year follow-up was available in 75 of the 77 patients (97.4%). During follow-up 49 of 75 patients (65.3%) maintained remission or presented mild relapse not requiring steroids while 26 of 75 patients (34.6%) had moderate to severe relapse requiring further steroid treatment. The cumulative probability of a course free from steroids was 93.3%, 82.6%, 78.6%, and 66.6% at 3, 6, 9, and 12 months, respectively. At multivariate analysis, increased C reactive protein at steroid weaning and penetrating complications were independent risk factors for further steroid requirement (OR 5.57, 95% CI 1.20-25.91, P= 0.001 and OR 4.20, 95% CI 1.76-10.04, P= 0.005, respectively). CONCLUSION: Despite an initial clinical response and successful steroid tapering, 35% of patients required further steroid treatment within 1 yr. An increased C reactive protein value, at steroid weaning, despite clinical remission, and penetrating complications may predict further steroid requirement in already steroid responsive patients.     

Growth after intestinal resection for Crohn's disease in children, adolescents, and young adults

OBJECTIVE: Growth before and after intestinal resection for Crohn's disease (CD) was examined in a group of children, adolescents, and young adults. METHODS: Retrospective chart review of patients who had intestinal resections as clinical management of complications of CD between 1985 and 1996. Pre- and postoperative measurements of weight and height were reviewed. Z-scores were computed for weight-forage (WAZ), height-for-age (HAZ), and weight-for-height (WHZ). Two tailed t tests were used to compare postoperative growth patterns. Significance was defined as p < 0.05. RESULTS: Twenty-five subjects (8 females, mean age 16.2+/-2.8 years with one operation, and 3 males, mean age 15.7 years with multiple operations) were identified. There were significant improvements in the postoperative growth patterns of subjects who had one operation: HAZ (-1.28+/-1.45 versus -0.98+/-1.37, p = 0.041), WAZ (-1.35+/-1.02 versus -0.74+/-0.93, p = 0.0006) and WHZ (-0.64+/-0.95 versus -0.23+/-0.81, p = 0.036). Furthermore, the magnitude of postoperative weight gain directly correlated with the age at CD diagnosis, R2 = 0.16, p = 0.046. Trends towards improved postoperative WAZ (-0.83 versus -0.49) and HAZ (-0.47 versus -0.27) were also observed in the three subjects who had multiple operations. CONCLUSION: The pattern of weight and height growth was improved after intestinal resection for CD. Nonetheless, close monitoring of postoperative growth is necessary especially in children diagnosed with CD at a young age.     

Long-term results of strictureplasty without synchronous resection for jejunoileal Crohn's disease

BACKGROUND: There have been several reports on strictureplasty for Crohn's disease. However, in most of them the majority of the patients underwent synchronous bowel resections. The efficacy of strictureplasty has been often attributed to the synchronous bowel resection. This study was undertaken to assess the long-term results of strictureplasty alone for jejunoileal Crohn's disease. METHODS: Forty-three patients who underwent 135 primary strictureplasties without synchronous resection for jejunoileal Crohn's disease between 1980 and 1997 were reviewed. Factors affecting reoperation rates were examined by using a multivariate analysis. RESULTS: There were no operative deaths. Intra-abdominal septic complications (abscess/fistula) developed in 4 patients (9%). Abdominal symptoms were relieved in all but two patients, who required further surgery within 6 months after operation. After a median follow-up of 9 years 21 patients (49%) required reoperation for small-bowel recurrence. A multivariate analysis using Cox's proportional hazard model showed that only age at operation (<35 years, hazard ratio 11.1 versus >35 years, P = 0.002) was an independent significant factor affecting the reoperation rate. Sex, duration of symptoms, smoking, previous small-bowel resection, steroids use, preoperative nutritional status, and site, number, or length of strictureplasties did not affect the reoperation rates. At present all the patients are asymptomatic and receiving neither medical treatment nor nutritional support. CONCLUSIONS: Strictureplasty is a safe and efficacious procedure for jejunoileal Crohn's disease in the long term. Only youth was an independent significant risk factor for recurrence requiring surgery.     

Long-term functional outcome after low anterior resection

OBJECTIVE: The purpose of this study was to compare long-term functional results of two methods of reconstruction after anterior rectal resection for cancer: low colorectal anastomosis and colonic J-pouch-anal anastomosis. SUMMARY BACKGROUND DATA: After anterior resection for mid or low rectal cancer, the decision to perform low colorectal or coloanal anastomosis is made intraoperatively, depending on the distance of the tumor from the anal verge. Functional results of these operations are considered to be similar one to two years after surgery. No study to date has compared long-term functional results after rectal excision followed by either low colorectal anastomosis or colonic J-pouch-anal anastomosis. METHODS: From 1987 to 1992, 173 patients underwent anterior resection for cancer located between 2 to 12 cm from the anal verge. All patients alive without recurrence were contacted by telephone interview for assessment of functional results. There were 47 patients with colonic J-pouch-anal anastomosis and 34 patients with low colorectal anastomosis. Minimum follow-up was three years for all patients (mean, 5 years). RESULTS: The two groups were well matched for gender, age, histologic stage, and use of adjuvant therapies. Patients with colonic J-pouch-anal anastomosis displayed significantly better function in terms of frequency of defecation (1.57±1vs. 2.79±1;P=0.001) and presence of irregular transit or stool clustering (30vs. 71 percent;P=0.003). Patients who underwent colonic J-pouch-anal anastomosis were significantly less likely to require constipating agents (4vs. 21 percent;P=0.03) or need to follow a estricted diet (14vs. 41 percent;P=0.01). Results concerning the need to defecate again within one hour and disruption of social or professional life as a consequence of surgery showed a tendency in favor of colonic J-pouch-anal anastomosis. CONCLUSION: Colonic J-pouch-anal anastomosis offers superior long-term function compared with low colorectal anastomosis after radical treatment of rectal cancer. Preservation of a short rectal segment followed by a straight colorectal anastomosis does not offer any clinical advantage over colonic J-pouch-anal anastomosis.Poster presentation at the Digestive Disease Week and the meeting of the American Gastroenterological Association, Washington, D.C., May 11 to 14, 1997.     

Risk factors for recurrence after bowel resection for Crohn's disease

BACKGROUND Complications of Crohn's disease such as intestinal obstruction, fistula or perforation often need surgical treatment. Nearly 70%-80% patients with Crohn's disease would receive surgical treatment during the lifetime. However, surgical treatment is incurable for Crohn's disease. The challenge of recurrence postoperatively troubles both doctors and patients. Over 50% patients would suffer recurrence postoperatively. Some certain risk factors are associated with recurrence of Crohn's disease.AIM To evaluate the risk factors for endoscopic recurrence and clinical recurrence after bowel resection in Crohn's disease.METHODS Patients diagnosed Crohn's disease and received intestinal resection between April 2007 and December 2013 were included in this study. Data on the general demographic information, preoperative clinical characteristics, surgical information, postoperative clinical characteristics were collected. Continuous data are expressed as median(inter quartile range), and categorical data as frequencies and percentages. Kaplan-Meier method was applied to estimate the impact of the clinical variables above on the cumulative rate of postoperative endoscopic recurrence and clinical recurrence, then log-rank test was applied to test the homogeneity of those clinical variables. Multivariate Cox proportional hazard regression analysis was performed to identify the risk factors of postoperative endoscopic recurrence and clinical recurrence.RESULTS A total of 64 patients were included in this study. The median follow-up time for the patients was 17(9.25-25.75) mo. In this period, 41 patients(64.1%) had endoscopic recurrence or clinical recurrence. Endoscopic recurrence occurred in34(59.6%) patients while clinical recurrence occurred in 28(43.8%) patients, with the interval between the operation and recurrence of 13.0(8.0-24.5) months and 17.0(8.0-27.8) mo, respectively. In univariate analysis, diagnosis at younger age(P 0.001), disease behavior of penetrating(P = 0.044) and preoperative use of anti-tumor necrosis factor(TNF)(P = 0.020) were significantly correlated with endoscopic recurrence, while complication with perianal lesions(P = 0.032) and preoperative use of immunomodulatory(P = 0.031) were significantly correlated with clinical recurrence. As to multivariate analysis, diagnostic age(P = 0.004),disease behavior(P = 0.041) and preoperative use of anti-TNF(P = 0.010) were independent prognostic factors for endoscopic recurrence, while complication with perianal lesions(P = 0.023) was an independent prognostic factor for clinical recurrence.CONCLUSION Diagnostic age, disease behavior, preoperative use of anti-TNF and complication with perianal lesions were independent risk factors for postoperative recurrence in Crohn's disease.     

Chronic intestinal pseudo-obstruction in patients with extensive bowel resection for Crohn's disease

We report three cases of severe chronic intestinal pseudo-obstruction after extensive bowel resection for Crohn's disease. The patients retained less than or equal to 150 cm jejunum in continuity with the left half of the colon and had no evidence of inflammatory activity in the remaining bowel. Total parenteral nutrition was required, since even very small meals caused abdominal distention, pain, and vomiting. Two patients had a sigmoidostomy constructed, which alleviated the symptoms and enabled a normal oral intake, but only temporarily in one of the patients. Even with a sigmoidostomy the patients needed supplementary parenteral nutrition because of severe malabsorption with high stomal output.     

Long-term outcome of infliximab combined with surgery for perianal fistulizing Crohn’s disease

AIM:To evaluate the efficacy and long-term outcome of infliximab combined with surgery to treat perianal fistulizing Crohn’s disease(CD).METHODS:The work was performed as a prospective study.All patients received infliximab combined withsurgery to treat perianal fistulizing CD,which was followed by an immunosuppressive agent as maintenance therapy.RESULTS:A total of 28 patients with perianal fistulizing CD were included.At week 30,89.3%(25/28)of the patients were clinically cured with an average healing time of 31.4 d.The CD activity index decreased to70.07±77.54 from 205.47±111.13(P0.01)after infliximab treatment.The perianal CD activity index was decreased to 0.93±2.08 from 8.54±4.89(P0.01).C-reactive protein,erythrocyte sedimentation rate,platelets,and neutrophils all decreased significantly compared with the pretreatment levels(P0.01).Magnetic resonance imaging results for 16 patients after therapy showed that one patient had a persistent presacral-rectal fistula and another still had a cavity without clinical symptoms at follow-up.After a median follow-up of 26.4 mo(range:14-41 mo),96.4%(27/28)of the patients had a clinical cure.CONCLUSION:Infliximab combined with surgery is effective and safe in the treatment of perianal fistulizing CD,and this treatment was associated with better longterm outcomes.     

Changes in small intestinal epithelial expression of MHC Class II antigen after terminal ileal resection for Crohn's disease

Aphthous lesions in the neoterminal ileum from patients operated for Crohn's disease are an early sign of recurrence that can be identified during ileocolonoscopy. The origin of these lesions was studied in nine patients treated by terminal ileal resection and right hemicolectomy for complicated Crohn's disease. During surgery the neoterminal ileum was turned inside out, the mucosa was carefully inspected and two large mucosal biopsies were obtained. The same procedure was carried out in seven patients operated for other diseases. Four to six months after surgery endoscopy of the neoterminal ileum was carried out and multiple biopsies were obtained from the neoterminal ileum. Another follow-up colonoscopy with biopsies was carried out one year after the operation. The operative specimens and the per- and postoperative biopsies were submitted to routine microscopy and immuno- and enzyme-histochemistry. None of the Crohn's patients had macroscopic lesions in the neoterminal ileum at operation and only one had microscopic signs of inflammation and a positive section margin. Four-six months after operation all Crohn's patients had active aphthous lesions in a 5–20 cm segment of the neoterminal ileum at endoscopy. Biopsies taken at this time showed microscopic features which were not observed in biopsies from control subjects: an increase of HLA-DR⁺, ATPase⁺ dendritic cells in the ileal mucosa and a defective expression of MHC class II antigens by the small intestinal epithelial cells. MHC class II expression by the small intestinal epithelial cells returned towards normal after one year. The lesions observed in the early postoperative biopsies indicate that an early local temporary dysfunction of the immunologic system may be important in the pathogenesis of anastomotic recurrence in Crohn's disease.     

Neoterminal ileal blood flow after ileocolonic resection for Crohn's disease.

Endoscopic laser Doppler flowmetry was used to measure neoterminal ileal blood flow in 16 patients who had undergone ileocolonic resection for Crohn's disease and had since remained clinically and biochemically free of disease, and eight control patients who had undergone similar surgery for colonic carcinoma. Four patients with clinically active Crohn's disease of the terminal ileum were also studied. Neoterminal ileal recurrence in those with inactive Crohn's disease was graded endoscopically. The median and minimum of five local blood flow measurements performed in each patient were inversely correlated with the endoscopic recurrence grade (r = -0.52, p = 0.04 and r = -0.63, p = 0.01 respectively). Relative to the control group, median blood flow was non-significantly lower in the inactive Crohn's disease group as a whole (p > 0.05) but was significantly reduced in patients with active disease (p = 0.02). A progressive reduction in tissue perfusion may accompany recurrence of Crohn's disease while at a subclinical stage.