Crohn's disease: risk of recurrence and reoperation in a defined population.

Two hundred and ten patients with Crohn's disease (CD) were identified in an epidemiological survey of inflammatory bowel disease in the Leiden Health Care Region of the Netherlands. The survey included all patients with CD seen between 1979-1983. The duration of disease ranged from less than one year to 48 years. Of the 210 patients with CD, 118 (56%) underwent surgical resection. Sixty one had an ileocaecal resection, 14 a proctocolectomy, in seven cases as a two stage procedure; 12 a segmental colectomy with end-to-end anastomosis and eight a subtotal colectomy with ileostomy. Twenty-one of these 118 patients (18%) had recurrences requiring reoperation; in 11 because of recurrence at the anastomotic site. Life table analysis showed that after 10 years 17% of patients required further resection for recurrence and 8% for relapse. By 20 years the rate of recurrence had risen to 56%. Patients over the age of 30 at first resection were at 1.5 fold greater risk of requiring further surgery than younger patients. The initial site of disease played no role in recurrence and there was no evidence that preoperative disease duration, delay in diagnosis, or late surgery had any effect on recurrence rates. This is one of the few community based studies to measure recurrence and relapse. A balanced appraisal is that surgery is not permanently curative, but the need for further resection may be lower than previously suggested.     

Surgical results in Crohn's disease--an analysis in view of cumulative risk or recurrence and reoperation

Forty nine cases with Crohn's disease operated at our department were analyzed in view of cumulative risk of reoperation and recurrence. Cumulative risk of reoperation was 22% at five years and 40% at ten years. Cumulative risk of recurrence after "curative" resection in thirty four cases was 53% at five years and 73% at ten years. Both risks were the highest in ileal type and the lowest in colonic type. Cumulative risk of relapse in ileocolic type after non-"curative" resection was 67% at five and ten years, which showed no significant difference with cumulative risk of recurrence after "curative" resection. Cumulative risk of recurrence after "curative" resection with proximal resection margin longer than 10 cm had no significant difference from the group with shorter margin. Cumulative risk of recurrence and reoperation after reoperation was a little higher than after initial operation, but they showed no statistical difference. In conclusion, there is no need to stick to "curative" resection, and it is enough to have the resection margin no longer than 10 cm. It is essential not to spoil the quality of life by excessive resection.     

Abscesses in Crohn's disease: outcome of medical versus surgical treatment

GOALS: To compare the long-term outcome of medical, percutaneous, and surgical treatment of abdominal and pelvic abscesses complicating Crohn's disease. STUDY: All patients with Crohn's disease and an abdominal abscess treated at one institution during a 10-year period were retrospectively identified. We reviewed hospital and outpatient records and contacted patients for telephone interviews. Outcome measures included abscess recurrence, subsequent surgery for Crohn's disease, and medications used at the time of most recent follow-up. RESULTS: Fifty-one subjects were identified, with a mean follow-up of 3.75 years. Fewer patients developed recurrent abscesses after initial surgical drainage and bowel resection (12%) than patients treated with medical therapy only or percutaneous drainage (56%) (p = 0.016). One half of the patients treated nonoperatively ultimately required surgery, whereas only 12% of those treated with initial surgery required reoperation during the follow-up period (p = 0.010). Most failures of nonoperative therapy occurred within 3 months. Medication use was similar between the treatment groups at the time of most recent follow-up. CONCLUSIONS: In this series, surgical management of abscesses in Crohn's disease was more effective than medical treatment or percutaneous drainage for prevention of abscess recurrence. However, nonoperative therapy prevented subsequent surgery in half of the patients and may be a reasonable treatment option for some patients.     

Recurrent small bowel Crohn's disease is more frequent after subtotal colectomy and ileorectal anastomosis than proctocolectomy

The cumulative probability of reoperation for recurrent ileal Crohn's disease at five years was: 17 percent following ileocecal resection, 19 percent following proctocolectomy, and 28 percent after ileorectal anastomosis. At ten years, the rate of ileal recurrence was significantly less after proctocolectomy; 24 percent as compared with 43 percent for ileorectal anastomosis (P less than 0.01), whereas ileocecal resection assumed an intermediary position with 35 percent.     

Factors influencing postoperative recurrence of Crohn's disease in childhood.

We have reviewed the outcome of all patients undergoing their first intestinal resection for Crohn's disease at this hospital between 1970 and 1987. Recurrence rates, defined by recurrent intestinal symptoms and radiological confirmation of mucosal disease, were calculated using survival analysis. Age, sex, anatomical location of disease, indication for surgery, preoperative duration of symptomatic disease, use of preoperative bowel rest, and pathological features of the resected bowel were analysed individually and jointly as potential risk factors influencing postoperative recurrence of disease. Eighty two patients (age, mean (SD) 14.8 (2.5) years) underwent intestinal resection and were followed postoperatively for a minimum of one year (mean 5.3 (3.3) years). Anatomical location of disease, indication for surgery, and preoperative duration of symptomatic disease were the only factors that significantly influenced the duration of the recurrence free interval. Patients with diffuse ileocolonic inflammation experienced earlier recurrence (50% at one year) than children with predominantly small bowel disease (50% recurrence at five years, p less than 0.0001). Failure of medical therapy independent of disease location as the sole indication for surgery was associated with an earlier relapse than when surgery was performed for a specific intestinal complication such as abscess or obstruction (p less than 0.003). Patients undergoing resection within one year of onset of symptoms experienced delayed recrudescence of active disease (30% recurrence by eight years) compared with patients whose preoperative duration of symptomatic disease was longer (50% recurrence by four years when preoperative duration of disease was one to four years and 50% by three years when disease had been present greater than four years preoperatively, p = 0.03). The mean height velocity of patients with growth potential increased from 2.4 (2.3) cm per year preoperatively to 8.1 (3.4) cm per year in the first postoperative year (p=0.0001). These results support an early approach to surgery in the management of ileal Crohn's disease with or without caecal or right colonic involvement, especially when complicated by persistent growth failure. The higher recurrence rates in more diffuse ileocolonic disease emphasise the need for alternative treatment strategies in these children.     

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.     

Surgical treatment of low-lying carcinoma of the rectum

The standard operative treatment of low-lying rectal cancer has been abdominoperineal resection. In the elderly patient, this treatment has significant risk. One-fourth of the patients had major complications and another one-fourth had minor complications. The operative mortality was 6.8 per cent for patients 65 years of age and over and 7.7 per cent for patients 70 years old and over. Patients with metastatic disease at the time of diagnosis had a dismal prognosis despite treatment with abdominoperineal resection. Postoperative pelvic radiotherapy should help reduce pelvic recurrence. Generally, patients with tumors less than 5 cm in diameter and less than 5 cm from the dentate line should be considered for initial transanal excision. It appears that very good local tumor control can be achieved by transanal excision for tumors confined to the bowel wall. Only 6.9 per cent of patients with tumors confined to the bowel wall had lymph node metastasis. The low risk of occult lymph node metastasis from tumors confined to the bowel wall is offset by the operative risk of abdominoperineal resection. Further evaluation of transanal excision of selected rectal cancers is indicated. Patients with villous adenomas with superficial carcinoma can be adequately treated repetitively with transanal local excision. In this case, there was a 50 per cent local recurrence rate. Local recurrence occurred in some patients five or more years after the initial treatment, thus emphasizing the need for prolonged close proctoscopic follow-up.     

Factors affecting recurrence following resection for Crohn's disease

The records of 187 patients with Crohn's disease who underwent resectional surgery were analyzed to evaluate the effect of several clinical and histologic features on the recurrence rate. Recurrence was defined as the need for re-resection. The data were analyzed by the life-table method. Age, sex, age at onset of disease and at time of resection, family history, presence of granuloma, and microscopic involvement at the line of resection did not affect the recurrence rate. The distribution of the disease and duration of symptoms before primary resection did influence the rate of re-resection. Patients with predominantly large bowel disease (N=56) were found to have a higher rate of re-resection (45 percent) when compared with 32 percent in patients with small bowel involvement (N=94) and with 35 percent in patients with both small and large bowel involvement (N=37) (P=0.04). a detailed review, an analysis of the literature, and a comparison with our results are made.     

The dilemma of Crohn's disease: long-term follow-up of Crohn's disease of the small intestine

Summary Seventy-four patients having primary Crohn's disease of the small intestine have had follow-up studies for at least 10 years after initial resection, and the results of treatment are presented. The commonest indication for operative treatment was obstruction, followed by fistula formation, intractability, abscess formation, and free perforation. Disease recurred in 69 per cent of patients in this series, and 55 per cent of this group required further operative treatment. It is necessary to have a lengthy follow-up period if we are to appreciate fully the serious nature of the recurrence problems of Crohn's disease of the small intestine.     

Perforating and non-perforating indications for repeated operations in Crohn's disease: evidence for two clinical forms.

The surgical indications in 770 patients with Crohn's disease undergoing intestinal resection at The Mount Sinai Hospital from 1960-83 have been reviewed. Surgical indications were divided into two principal categories: 375 cases with perforating indications and 395 cases non-perforating. Among 292 patients who underwent second operations for recurrent Crohn's disease, the indications for second operation were closely dependent on the indication for primary resection. Second operations were undertaken for perforating indications much more often among cases where the initial indication had been perforating, than among those whose initial indications had been non-perforating (73% v 29%, p less than 0.00001). This trend to similarities in the indications which bring patients to surgery was maintained within each anatomical category of Crohn's disease and even between second and third operations (p less than 0.001). Operations for perforating indications were followed by reoperation approximately twice as fast as operations for non-perforating indications, whether going from first to second operation (perforating 4.7 v non-perforating 8.8 years, p less than 0.001), or from second to third (perforating 2.3 v non-perforating 5.2 years, p less than 0.005). Crohn's disease thus seems to occur in two different clinical patterns, independent of anatomic distribution. These are a relatively aggressive perforating type and a more indolent non-perforating type, which tend to retain their identities between repeated operations and to influence the speed with which reoperation occurs.     

Life prospects and quality of life in patients with Crohn's disease.

A regional prevalence group of 106 patients with Crohn's disease were interviewed about their familial, social, and professional conditions. The results were compared with results from similar interviews of an age and sex matched control group of 75 previously healthy patients admitted to the hospital for acute diseases of less than 28 days' duration. An equal percentage of the patients and the controls were married (67% vs 71%) and had become parents (68% vs 79%). The number of children was slightly lower among Crohn's disease patients. The occurrence of familial problems and sexual problems did not differ among patients and controls. The intake of sedatives was low in both groups and no difference was found in alcohol and tobacco intake between patients and controls. A combined score for social activities comprising cultural, sporting, educational and private social arrangements showed that about one-third of patients and controls had high social activity and about half of both groups had moderately high social activity. A similar physical activity score showed no difference between the two groups. The socioeconomic level of the Crohn's disease patients was slightly, but significantly higher than that of the controls. Sixty five per cent of Crohn's disease patients were employed, 64% of controls; 6% and 7% respectively unemployed. Three per cent of Crohn's disease patients had disablement pension. Of Crohn's disease patients employed, a higher percentage (77%) had remained in the same job for more than five years (64% of controls). The number of sick leave days during previous year was less than 11 in 72/69% of patients and controls. In spite of these objectively good results 54% of patients with Crohn's disease felt exacerbations of their disease strained their professional and personal life. During the previous year 23% reported decreased working capacity and 21% reported decreased leisure activities, compared with their own expectations.     

Survival of 727 patients with single carcinomas of the large bowel

The outcome of 727 patients presenting with solitary colorectal carcinoma over a seven-year period is reviewed. Of the patients, 52 per cent were females 45 per cent were over 70 years and 31 per cent had an emergency admission. Of the tumors, 43 per cent occurred in the rectum and 40 per cent were stage D (not treated curatively). Predisposing causes included inflammatory bowel disease (n=12) and abdominal irradiation (n=6); associated adenomatous polyps were present in 22 per cent of resection specimens. Hospital mortality rates (20 per cent overall) were adversely affected by emergency admission (36 per cent), age>70 years (29 per cent) and advanced, stage D disease (31 per cent). Corrected overall five-year survival rate was 32 per cent and, after curative resection, 59 per cent. Of patients in whom curative resection included contiguous organs, 47 per cent survived five years. Survival was reduced in patients over 70 years (26 per cent), in emergency admissions (24 per cent), in poorly differentiated tumors (18 per cent), and if tumor fixity was present (14 per cent). Factors contributing to a favorable outlook included a long history (greater than one year) and a tumor situated in the left colon. Recurrence developed in 47 per cent of patients surviving curative resection and was seldom diagnosed at a curable stage. This work was supported by a grant from the Wellcome Trust, United Kingdom. Presented at the Association of Surgeons of Great Britain and Ireland, Dundee, April 1984.     

Factors influencing the morbidity of colostomy closure

In a series of 80 colostomy closures, a total complication rate of 26 per cent was found, with a wound infection rate of 14 per cent and an anastomotic leak rate of four per cent. Patients having preoperative systemic antibiotics had fewer wound infections than those who did not (eight per cent versus 19 per cent). Delayed primary skin closure or closure by secondary intention was associated with less wound morbidity than was primary closure (ten per cent versus 17 per cent). However, the use of preoperative systemic antibiotics decreased the incidence of wound infection in those having primary skin closure (five per cent versus 27 per cent). Patients having diverticular disease had more wound infections (40 per cent) and greater overall morbidity (70 per cent). Older patients had a higher incidence of complications (24 per cent if less than 40 years and 45 per cent if greater than 50 years). Closure of left-sided colostomies was associated with a higher infectious complication rate (26 per cent versus 13 per cent). The time interval to colostomy closure was found to alter subsequent morbidity with a waiting period of one to two months associated with zero complications.     

Laparoscopic versus open bowel resection for Crohn's disease.

BACKGROUND: Laparoscopic bowel resection is an alternative to open surgery for patients with Crohn's disease requiring surgical resection. The present report describes a seven-year experience with the laparoscopic treatment of Crohn's disease compared with the open technique in a tertiary Canadian centre. PATIENTS AND METHODS: A retrospective analysis of 61 consecutive patients undergoing elective resection for Crohn's disease was carried out between October 1992 and June 1999. This analysis included 32 laparoscopic resections (mean age 33 years) and 29 open resections (mean age 42 years). Patient demographics were compared, as well as short and long term outcomes after surgery (mean follow-up 39 months). RESULTS: Patients in the laparoscopic group were younger and had fewer previous bowel surgeries than patients who had open resections. Indications for surgery and operative times were similar between the groups. Patients who underwent laparoscopic resections required fewer doses of narcotic analgesics. The resumption of bowel function after surgery, and tolerance of a clear liquid and solid diet was quicker in the laparoscopic group. Patients who underwent laparoscopic resections had significantly shorter hospital stays than those who underwent open resections. Fifteen patients (48.4%) in the laparoscopic group experienced recurrence of disease compared with 13 patients (44.8%) in the open group. In both groups, the most common site of recurrence was at the anastomosis. The disease-free interval was the same length for both groups (23.9+/-17.3 months for the laparoscopic resection patients compared with 23.9+/-20.2 months for the open resection patients; P=1.00). CONCLUSIONS: Laparoscopic resection for Crohn's disease can be performed safely and effectively. Quicker resumption of oral feeds, less postoperative pain and earlier discharge from hospital are advantages of the laparoscopic method. No differences in the recurrence rate or the disease-free interval were noted.     

Strictureplasty in diffuse Crohn's jejunoileitis: safe and durable

PURPOSE: As an alternative to resection, strictureplasty may allow for preservation of intestinal length and avoidance of short-bowel syndrome in patients with diffuse Crohn's jejunoileitis. However, the long-term durability of the procedure and its safety have not been confirmed. The purpose of this study was to report our experience with strictureplasty for diffuse Crohn's jejunoileitis. METHODS: Between 1984 and 1999, 123 patients underwent a laparotomy that included an index strictureplasty for diffuse jejunoileitis. Patient history, operative details, and postoperative morbidities were obtained by chart review. Nineteen patients (15 percent) were receiving total parenteral nutrition for short-bowel syndrome, and 81 (66 percent) were taking chronic steroids. Total number of strictureplasties performed was 701 (median, 5/patient). Seventy percent of patients underwent a synchronous bowel resection. Follow-up information was determined by personal or phone interviews. Recurrence was defined as the need for reoperation, and risk was calculated by the Kaplan-Meier method. Patients with diffuse jejunoileitis were also compared with 219 patients with limited small-bowel Crohn's disease undergoing strictureplasty. RESULTS: The overall morbidity rate was 20 percent, with septic complications occurring in 6 percent. The surgical recurrence rate was 29 percent with a median follow-up period of 6.7 (range, 1-16) years. The recurrence rate in diffuse jejunoileitis patients did not differ from that seen in patients with limited small-bowel Crohn's disease (P = 0.38). Short duration of disease and short interval since last surgery were significant predictors of accelerated recurrence (P = 0.008 and 0.04, respectively). CONCLUSIONS: Strictureplasty is a safe and durable alternative to resection in diffuse Crohn's jejunoileitis. Patients with a short duration of disease and short interval since last surgery are at higher risk for accelerated recurrence. Patients with diffuse jejunoileitis do not appear to be at higher risk for recurrence than patients with more limited Crohn's disease.     

Efficacy of nutritional therapy for perforating and non-perforating Crohn's disease

BACKGROUND/AIMS: Enteral nutrition is the currently established primary therapy for Crohn's disease in Japan. We examined the effects of postoperative nutritional therapy in patients with perforating type and non-perforating type Crohn's disease. METHODOLOGY: We retrospectively reviewed the records for 218 patients who underwent surgical interventions for Crohn's disease in our hospital between January 1, 1974 and September 30, 2001. They were divided into four groups: 92 patients in the non-perforating type (NP type) + Elemental Diet (ED) group had received ED therapy and nutritional education, 22 patients in the NP type + NoED group had not received ED therapy or nutritional education, 88 patients in the perforating type (P type) + ED group and 16 patients in P type + NoED group. We evaluated the incidence of reoperation rate for each group. RESULTS: Patients with a postoperative ED therapy demonstrated a significant decrease in the incidence of second resection. The incidence of second resection in the NP type + ED group was significantly lower than that of the other groups. The NP type + NoED group and the P type + ED group followed similar courses. CONCLUSIONS: In patients with Crohn's disease postoperative ED therapy and nutritional education is effective in reducing the incidence of second resection. It appears that postoperative ED therapy and nutritional education is more important in patients with P type Crohn's disease.     

Crohn's disease of the distal ileum.

A clinical and statistical analysis has been undertaken in a consecutive series of 227 patients with Crohn's disease involving the distal ileum under long-term review between 1944 and 1978. We have determined the long-term prognosis, cumulative reoperation rates after each resection, mortality rates, and their causes. Actuarial analysis has shown that the reoperation rates are similar after first, second, and third resections. There was no evidence that additional operations increase the risk of yet more resections. Reoperation rates were very little influenced by the age at diagnosis of the underlying Crohn's disease. A short interval from diagnosis of Crohn's disease to the first resection tended to increase the reoperation rate in the short term but there was no overall long-term effect. There was a two-fold increase in mortality risk when compared with the general population. Half the deaths were unrelated to the underlying Crohn's disease and, in this group, the incidence and causes were similar to those expected in the general population matched for age, sex, and years at risk. Of the disease related deaths many occurred in the early years of experience. Only four patients in the series have died of Crohn's disease in the last 10 years. One hundred and ninety-three patients are still alive after a mean interval of 16.1 years from the diagnosis of Crohn's disease. Full information is available on 185, of whom 161 are well and symptom free. Seven have minor problems, while 17 are unwell (nine with radiological evidence of recurrent disease).     

Diagnosis and treatment of diffuse ileojejunitis.

Thirteen patients with diffuse ileojejunitis have been diagnosed and treated by us over the past ten years. The disease bears close resemblance to Crohn's disease and may represent a variant of it. No clearcut relationship to celiac sprue was observed in this group of patients. Therapeutic success was obtained in the majority of patients treated with the anti-inflammatory drugs, sulfasalazine and steroids, with four patients requiring resectional surgery, all others manageable by nonsurgical means. There was no mortality in this series of patients.     

Long term prognosis of Crohn''s disease with onset in childhood and adolescence

The long term outcome has been determined in 67 children with Crohn's disease whose symptoms started at or before 16 years of age. The mean period of follow up was 15.0 years (range 1.5-47 years). The number of children diagnosed in each quinquennium has not increased. Nearly all patients had gastrointestinal symptoms at presentation, but in some cases these were only elicited on careful enquiry. Only four children presented with growth retardation alone. Twenty one per cent of the children had diffuse small bowel disease at onset or during the period of review and posed major problems in management with high morbidity and mortality. They were generally treated medically to suppress disease activity and surgical intervention was restricted to resection of local stricture formation. The outcome in distal ileal +/- right colonic disease was similar to that in the adult. Patients with colonic disease (27% of total) were treated medically but 83% required surgical resection after a mean interval of only four years (range 0-9 years). Growth failure occurred in 21 children (height and weight less than 3rd centile) and 11 of these had a period of catch up growth; 10 after resection (ileal +/- right colon resected, eight; colonic resection, two) and one after medical treatment. Ten have permanent growth and height retardation, of whom four had diffuse small bowel disease and three had early recurrence after surgical resection. Nine children have died during the period of review, of whom six had diffuse small bowel disease. Despite the high morbidity, 38 of the 58 survivors are now well with no evidence of recurrent disease. A further 14 are well, but with radiological evidence of residual (colon, three; diffuse small bowel, eight) or recurrent (three) disease. Only six have symptomatic disease at present.     

Colorectal carcinoma in patients less than 40 years of age

Between 1960 and 1979, 37 patients, ranging in age from 18 to 40 years, were treated for colorectal cancer. Symptoms typical of colorectal malignancy had been present for an average of 10.4 months; a positive family history, previous colonic disease, or immunosuppression was present in 22 patients (59 per cent). Distribution of lesions was unusual in that only 40 per cent were within reach of the sigmoidoscope, and only 7.5 per cent could be palpated on rectal examination. Dukes' staging at diagnosis was improved in distribution to that reported in the adult population (51 per cent localized vs. 40.1 per cent). Histologic characteristics of the tumors were not unusual; however, incidence of poorly differentiated (18.9 per cent) and mucin-producing (10.8 per cent) cancers was increased. Perineural invasion was associated with disseminated disease. Vascular invasion was associated with disseminated disease and poor prognosis. Overall fiver-year survival was 56.8 per cent. Five-year survival in 24 patients undergoing potentially curative resection increased to 70.8 per cent. Colorectal carcinoma in patients under 40 years of age is unusual, and delay in diagnosis is common. The distribution of lesions is more homogeneous than that seen in older patients, and high-grade malignancies are more frequent. Survival data in this series are more favorable than those generally reported. Improved five-year survival following potentially curative resection (70.8 per cent) stresses the need for early diagnosis and treatment Read at the meeting of the American Society of Colon and Rectal Surgeons, Hollywood, Florida, May 11 to 16, 1980. Supported in part by the Roessler Foundation and the American Cancer Society.