Medical management of postoperative recurrence in Crohn's disease

More than half of Crohn's disease patients require surgery during the course of their disease. Although endoscopic recurrence does not necessarily imply that patients have symptom recurrence, the high need for repeated surgery indicates that lesions gradually developing after surgical remission lead to fibrostenosis or other complications. Despite multiple clinical trials a clear medical strategy to prevent disease recurrence has not been identified. Future well designed collaborative trials with specified end points are needed to optimize clinical practice in the prevention of postoperative Crohn's disease recurrence.     

Pediatric Crohn's disease: risk factors for postoperative recurrence

OBJECTIVE: Postoperative recurrence of Crohn's disease in adults has been extensively studied; however, the course of Crohn's disease after surgery in children has not been well defined. The aim of this study was to examine the postoperative course of pediatric Crohn's disease and the factors that may predict early postoperative recurrence. METHODS: We identified 100 resective surgeries in 79 children with Crohn's disease seen at the Children's Hospital of Philadelphia between 1978 and 1996. A retrospective, multivariable analysis of factors potentially influencing postoperative clinical recurrence was performed. Preoperative and postoperative height measurements were compared, and z scores were computed for height-for-age. Two-tailed t test was used for the analysis. RESULTS: Clinical recurrence rates were 17% at 1 yr, 38% at 3 yr, and 60% at 5 yr. Patients with colonic Crohn's disease had a significantly shorter postoperative recurrence-free interval (median 1.2 yr) than patients with ileocecal (median 4.4 yr) or diffuse disease (median 3.0 yr) (p = 0.01). On multivariable analysis, a high Pediatric Crohn's Disease Activity Index at the time of surgery (p = 0.01) and preoperative use of 6-mercaptopurine (6-MP) (p < 0.005) were also independently associated with higher postoperative recurrence rates. There was a significant improvement in z scores for height (p = 0.04) after surgery. CONCLUSIONS: In children undergoing resective surgery for Crohn's disease, high rates of postoperative Crohn's disease recurrence are associated with severe disease at the time of surgery, colonic Crohn's disease, and the preoperative use of 6-MP. Patients who require preoperative use of 6-MP are likely to suffer from a more aggressive disease and would benefit from postoperative 6-MP prophylaxis. Height growth was improved after intestinal resection for Crohn's disease.     

Role of ultrasonography in the diagnosis of postsurgical recurrence of Crohn's disease

Objective: Ultrasonography is a valid tool in the diagnosis of Crohn's disease, but its sensitivity, specificity, and overall accuracy in the diagnosis of postoperative recurrence are still not well established. The aim of this study was to evaluate the accuracy of ultrasonography compared with endoscopy in the diagnosis of postoperative recurrence of Crohn's disease.
Methods: Forty-seven patients resected for Crohn's ileitis were studied by ultrasonography and colonoscopy to detect possible recurrence of the disease; 10 patients operated on for cancer of the right colon were used as controls. Six patients with Crohn's disease were excluded from the study because of failure to endoscopically reach the anastomosis; the remaining 41 patients had both ultrasonography and colonoscopy over a period of 14 days. Sonographic recurrence was defined as the presence of >5 mm thickness of the ileal wall.
Results: Sensitivity, specificity, and overall accuracy of ultrasonography in diagnosis of postoperative recurrence were 81%, 86%, and 83% respectively. Positive predictive value was 96% and negative predictive value was 57%.
Conclusion: This study is the first to assess the role of ultrasonography in comparison with endoscopy in detecting Crohn's disease recurrence after surgery. Our data suggest that ultrasonography should be used first in the case of clinical suspicion of Crohn's disease recurrence, reserving ileocolonoscopy for negative or uncertain cases.     

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.     

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.     

Tobacco use is associated with accelerated clinical recurrence of Crohn's disease after surgically induced remission

GOALS: To study the association between tobacco exposure and postoperative clinical recurrence in Crohn's disease patients and quantify the time to clinical relapse following surgical resection. BACKGROUND: It is well accepted that cigarette smoking has a negative impact on postoperative course in Crohn's disease. However, the effect of smoking to hasten clinical recurrence has not been clearly delineated. STUDY: We reviewed medical records of patients undergoing surgical resection for medication-refractory disease within a 5-year period. Patients were followed for a period of 250 weeks. Outcomes were compared between smokers and nonsmokers and stratified by gender. RESULTS: Fifty-nine patients were studied. Sixty-nine percent of smokers versus 23% of nonsmokers had recurrent symptoms (P = 0.02) by the end of the observation period. There was no difference in the mean ages, gender, disease location, use of postoperative medications, or number of postoperative visits (P > 0.09). Smoking was associated with an increased risk of clinical recurrence [odds ratio 2.96 (95% confidence interval, CI 1.5-5.6)]. The time to clinical relapse for smokers was 130 weeks versus 234 weeks in nonsmokers (P < 0.001). CONCLUSION: Smoking is associated with clinical recurrence of Crohn's disease, and the time to clinical recurrence in smokers is shorter. Strategies for smoking cessation are warranted.     

Postoperative maintenance of Crohn's disease remission with 6-mercaptopurine, mesalamine, or placebo: a 2-year trial

BACKGROUND & AIMS: No therapy has been shown to reliably prevent the evolution of postoperative recurrence of Crohn's disease. The aim of the current trial was to compare 6-mercaptopurine (6-MP) and mesalamine with placebo for the prevention of clinical, endoscopic, and radiographic recurrence of Crohn's disease after resection and ileocolic anastomosis. METHODS: Five centers randomized 131 patients to receive 6-MP (50 mg), mesalamine (3 g), or placebo daily in a double-blind, double-dummy trial. Patients had clinical assessments at 7 weeks and then every 3 months; colonoscopy at 6, 12, and 24 months; and small bowel series at 12 and 24 months. End points were clinical, endoscopic, and radiographic recurrence rates at 24 months. RESULTS: Clinical recurrence rates (intent to treat) by life-table analysis at 24 months were 50% (95% confidence interval [CI], 34%-68%), 58% (95% CI, 41%-75%), and 77% (95% CI, 61%-91%) in patients receiving 6-MP, mesalamine, and placebo, respectively. Endoscopic recurrence rates were 43% (95% CI, 28%-63%), 63% (95% CI, 47%-79%), and 64% (95% CI, 46%-81%), and radiographic recurrence rates were 33% (95% CI, 19%-54%), 46% (95% CI, 29%-66%), and 49% (95% CI, 30%-72%), respectively. 6-MP was more effective than placebo ( P < 0.05) at preventing clinical and endoscopic recurrence over 2 years. Patient withdrawals resulted in 69% of the study population evaluable for the clinical recurrence end point. CONCLUSIONS: 6-MP, 50 mg daily, was more effective than placebo at preventing postoperative recurrence of Crohn's disease and should be considered as a maintenance therapy after ileocolic resection.     

Changes in the bacterial flora of the neoterminal ileum after ileocolonic resection for Crohn's disease

OBJECTIVE: Bacterial agents have been implicated in the early recurrence of Crohn's disease after ileocolectomy. The aim of our study was to identify and quantify bacteria associated with the ileal mucosa in patients and controls and to correlate specific bacteria with recurrence. METHODS: The predominant bacterial microflora of the ileum were enumerated and identified, aerobically and anaerobically, in biopsies obtained at the time of surgery or by endoscopy from 61 patients with Crohn's disease and 10 ileocolectomy controls. The 61 specimens were comprised of 13 ileal biopsies taken from resection specimens, seven taken after ileostomy, and 41 taken after ileocolectomy. RESULTS: Ileocolectomy induced a significant increase in bacterial counts and variety in the neoterminal ileum in both patients and controls that was not observed in ileostomy biopsies. Comparison between patients and controls revealed greater numbers of Escherichia coli and enterococci in Crohn's disease and of bifidobacteria and ruminococci in controls. Early recurrence was associated with high counts of E. coli and bacteroides and the frequent isolation of fusobacteria. CONCLUSION: After ileocolectomy, colonization of the neoterminal ileum is increased. Our data suggest that increases in the populations of specific bacteria such as E. coli, enterococci, bacteroides, and fusobacteria may be important in postoperative recurrence of Crohn's disease.     

Pathogenesis of postoperative recurrence in Crohn's disease

The majority of patients with Crohn's disease (CD) require surgery during the course of their disease, but such surgery is typically not curative. Although some studies suggest that the disease state is theoretically reset to its earliest phase following surgery, disease phenotype and natural history of CD do not change significantly after surgery, leading to high rates of recurrence. Factors predisposing to this recurrence are not well defined, so there is a need for and a unique opportunity to develop a better understanding of the pathogenesis of recurrent inflammation and associated risk factors after an ileocolic resection. This paper reviews the postoperative disease outcome and evolution based on defining the combination of the patient's microbial flora, environmental exposure history, immune response and genetic make-up.     

Role of stapled and hand-sewn anastomoses in recurrence of Crohn's disease

BACKGROUND/AIMS: Anastomotic recurrence after bowel resection is a major problem in Crohn's disease surgery. The aim of this study is to compare recurrence rate after stapled side-to-side ileo-colonic anastomosis to those after stapled end-to-side or hand-sewn side-to-side anastomosis to distinguish the role of suture technique and anastomotic configuration in the prevention of Crohn's disease recurrence. METHODOLOGY: Eighty-four consecutive patients who had undergone ileo-colonic resection for Crohn's disease were enrolled: 12 of them had stapled side-to-side anastomosis, 36 stapled end-to-side anastomosis and 36 hand-sewn side-to-side anastomosis. We evaluated duration of operation, first bowel movement after operation, postoperative hospital staying, postoperative surgical complications, clinical recurrence and reoperation rate. The statistical analysis was performed using Student's t-test and Fisher exact test. Cumulative recurrence rates were compared using F Cox test and Kaplan-Meier method. RESULTS: No statistically significant difference between the three groups was observed in early postoperative follow up. The stapled side-to-side anastomosis group obtained a better symptom-free survival than the stapled end-to-side group (p=0.04). In the stapled and hand-sewn side-to-side groups reoperation rates were significantly lower than in the stapled end-to-side group (p=0.01 and p=0.05 respectively). CONCLUSIONS: All the three types of anastomosis were demonstrated to be equally safe in early postoperative outcome. A longer follow-up showed a significantly lower incidence of reoperation recurrence in the stapled and hand-sewn side-to-side anastomosis compared to the stapled end-to-side anastomosis group. This result may suggest the configuration of the anastomosis as the key point in the recurrence of anastomotic Crohn's disease.     

Predictability of the postoperative course of Crohn's disease

Eighty-nine patients who had been treated by ileal resection for Crohn's disease between 1979 and 1984 were included in a prospective cohort follow up to study the natural course of early postoperative lesions. Recurrent lesions were observed endoscopically in the neoterminal ileum within 1 year of surgery in 73% of the patients, although only 20% of the patients had symptoms. Three years after surgery, the endoscopic recurrence rate had increased to 85% and symptomatic recurrence occurred in 34%. The ultimate course of the disease was best predicted by the severity of the early postoperative lesions, as observed at ileoscopy. Clinical parameters that influenced outcome were preoperative disease activity, the indication for surgery, and the number of surgical resections. When patients were stratified for preoperative disease activity, the severity of lesions found at endoscopy remained a strong predictive factor for symptomatic recurrence. In 22 other patients submitted to "curative" ileal resection and ileocolonic anastomosis, the segment to be used as neoterminal ileum was carefully examined during surgery, and two large biopsies were taken before making the anastomosis. An ileoscopy was performed 6 months after surgery. Although all patients had a macroscopically normal neoterminal ileum and 19 had entirely normal biopsies at the time of surgery, 21 patients were found at ileoscopy to have developed ileitis involving a 15-cm segment (range, 4-30 cm), and 20 had unequivocal microscopic lesions on biopsies. These studies suggest that early lesions in the neoterminal ileum after Crohn's resection do not originate from microscopic inflammation present in this bowel segment at the time of surgery. The early postoperative lesions in the neoterminal ileum seem to be a suitable model to study the pathogenesis of Crohn's disease and also to evaluate new therapeutic modalities, either to prevent development of these early lesions or to treat progressive recurrence.     

Surgical therapy for Crohn's disease

Most patients with Crohn's disease will require at least one operation for that condition, either an operation to correct a complication of Crohn's disease (abscess, fistula, or bleeding) or for intractability (the failure of medical management to provide relief of disabling symptoms). Proper timing of surgery and careful preoperative preparation of the patient with special attention to control sepsis and to improving nutritional status will make the operation safer. Because of the tendency for Crohn's disease to progress despite medical or surgical therapy recurrences after operation are common and the surgical procedure should be limited to correcting the complication at hand. For Crohn's disease of the small bowel or of the terminal ileum and right colon, a conservative intestinal resection and anastomosis is usually the procedure of choice; nonresective procedures such as bypass and strictureplasty are useful in special situations. More than half of the patients so treated will eventually develop recurrence that may require one or more subsequent operations. The adverse effects of resection will be minimized by conservative surgery and by careful long-term management of the altered intestinal physiology. Some patients with Crohn's colitis have limited colonic disease where continence can be preserved by resection and anastomosis, although the recurrence rate is high. Total proctocolectomy for Crohn's colitis provides much better assurance of long-term freedom from recurrence but at the cost to the patient of a permanent ileostomy. Surgery for Crohn's disease is not curative but offers effective palliation for the complications of this progressive and poorly understood condition.     

Evaluation of postsurgical recurrence in Crohn's disease: a new indication for capsule endoscopy?

BACKGROUND: Recurrence after surgery to treat Crohn's disease is frequent and unpredictable. The efficacy of postsurgery capsule endoscopy in detecting recurrence in patients with Crohn's disease is yet to be confirmed. OBJECTIVE: To assess the safety, accuracy, and therapeutic impact of capsule endoscopy in these patients. DESIGN: Crohn's disease recurrence at the neoileum (Rutgeers score) was assessed in the patients by colonoscopy and capsule endoscopy. The M2A Patency Capsule (Given Imaging, Yoqneam, Israel) was administered 1 week before capsule endoscopy. Capsule endoscopy was performed within 2 weeks of colonoscopy. Investigators were blinded to the results of each technique. Patient comfort during the procedures was recorded. PATIENTS: Twenty-four patients with Crohn's disease with ileocolonic anastomosis were prospectively included. All patients were asymptomatic and did not receive any prophylactic treatment. MAIN OUTCOME MEASUREMENTS: Neoileum recurrence. RESULTS: A colonoscopy was performed in all patients, although the neoileum could not be reached in 3 of them. M2A Patency Capsule excretion was delayed in 2 patients; thus capsule endoscopy was given only to 22 patients. Recurrence was visualized with colonoscopy in 6 patients and with capsule endoscopy in 5. Ten additional recurrences were visualized only with capsule endoscopy. Moreover, proximal involvement was detected in 13 patients. Therapeutic management was modified in 16 patients. All patients preferred capsule endoscopy. CONCLUSIONS: Capsule endoscopy is more effective in the evaluation of recurrence after surgery for Crohn's disease and is better tolerated than colonoscopy. This is of significant therapeutic relevance.     

Medical therapy to reduce postoperative Crohn's disease recurrence

Clinical recurrence of Crohn's disease after surgical resection is a significant problem, with reported rates as high as 55% at 5 yr and 76% at 15 yr. Specific factors that predispose to postoperative recurrence of Crohn's disease have not been well defined. In addition, the underlying pathophysiology of recurrent disease and the reason for its localization to the neoterminal ileum are not well understood. Various operative techniques have been evaluated but none, aside from formation of an ostomy, has been shown to reduce the risk of recurrence. In contrast, there is increasing evidence that postoperative medical therapy has the potential to decrease the risk of postoperative recurrence. Historically, sulfasalazine may have a modest effect on reducing postoperative recurrence of ileal or ileocolonic disease. However, 5-ASA preparations that can selectively deliver mesalamine to the small bowel or anastomotic margin should be more effective. Indeed, in several studies and as confirmed by a meta-analysis, mesalamine has been demonstrated to reduce significantly postoperative recurrence of Crohn's disease. Metronidazole and 6-mercaptopurine or azathioprine also seem to be of benefit in postoperative prophylaxis of disease recurrence, but additional controlled studies are required to define better the efficacy and dose-response of these agents. Corticosteroids are ineffective at reducing postoperative recurrence.     

Prevention of relapse of Crohn's disease

Until a cure for Crohn's disease(s) is found, strategies that prolong the time spent in remission offer the greatest hope for reducing the morbidity and significant social costs associated with the disease. Medical therapy to date has been disappointing, and the search for a safe, effective therapy that could be offered at low cost continues. The aminosalicylates, so effective in ulcerative colitis, have shown, at best, minimal efficacy in maintaining remission in Crohn's disease. Conventional corticosteroids are not effective, and any reduction in time to relapse for budesonide-treated patients is measured in weeks not months. Azathioprine, 6-mercaptopurine, and methotrexate are effective in maintaining remission, but all three have significant side effects. Antibiotics may have a role to play. Biological therapy may be considered, but the issues of cost and long-term safety require evaluation. Future studies should segregate patients into two groups, those with a medically induced remission and patients whose concern is the prevention of postoperative recurrence.     

Recurrence after colectomy in Crohn's colitis

PURPOSE: Previous studies on recurrence and reoperation after colectomy in Crohn's colitis have been based on heterogeneous groups of patients, and divergent findings may be explained by referral biases and small numbers of patients. The aim of this study was to account for recurrence rates, present risk factors for recurrence after primary colectomy, and account for the ultimate risk of having a stoma after colectomy with ileorectal anastomosis in patients with Crohn's colitis. METHODS: Data on the primary resection, postoperative recurrence, influence of concomitant risk factors, frequency of stoma operations and proctectomy were evaluated retrospectively using multivariate analysis in a population-based cohort of 833 patients with Crohn's colitis. RESULTS: The cumulative 10-year risk of a symptomatic recurrence was 58 percent (95 percent confidence interval, 53-63 percent) and 47 percent (95 percent confidence interval, 42-52 percent), respectively, after colectomy with ileorectal anastomosis and segmental colonic resection. In colectomy with ileostomy, lower rates were found with respectively 24 percent (95 percent confidence interval, 18-30 percent) and 37 percent (95 percent confidence interval, 32-43 percent) after subtotal colectomy and proctocolectomy with ileostomy. The multivariate analysis showed that perianal disease, ileorectal anastomosis, and segmental resection were independent risk factors for postoperative recurrence. In 76 percent of patients with ileorectal anastomosis, a stoma-free function could be retained during a median follow-up of 12.5 years. CONCLUSION: Colectomy with ileorectal anastomosis or segmental resection is a feasible option in the surgical treatment of Crohn's colitis, although anastomoses, in addition to perianal disease, carry an increased risk of recurrent disease.     

Ornidazole for prophylaxis of postoperative Crohn's disease recurrence: a randomized, double-blind, placebo-controlled trial

BACKGROUND & AIMS: Crohn's disease almost inevitably recurs after ileocolonic resection, and effective prophylactic therapy has not been identified. We investigated the efficacy and safety of ornidazole, a nitroimidazole antibiotic, for the prevention of clinical recurrence of Crohn's disease after curative ileocolonic resection in a placebo-controlled double-blind clinical trial. METHODS: Eighty patients were randomized to ornidazole 1 g/day or placebo started within 1 week of resection and continued for 1 year. The primary end point was the proportion of patients with clinical recurrence at 1 year. Secondary end points were endoscopic recurrence at 3 months and 12 months after resection. RESULTS: Two patients in the ornidazole group withdrew consent and were not dosed. Ornidazole significantly reduced the clinical recurrence rate at 1 year from 15 of 40 (37.5%) patients in the placebo group to 3 of 38 (7.9%) patients in the ornidazole group (Fisher exact test, 8.03; P = .0046; odds ratio, 0.14; 95% confidence interval, 0.037-0.546). Ornidazole reduced endoscopic recurrence at 12 months from 26 of 33 (79%) in the placebo group to 15 of 28 (53.6%) in the ornidazole group (chi2 , 4.37; P = .037; odds ratio, 0.31; 95% confidence interval, 0.10-0.94). Endoscopic recurrence at 3 and 12 months predicted clinical recurrence. Significantly more patients in the ornidazole group dropped out from the study because of side effects (P = .041). CONCLUSIONS: Ornidazole 1 g/day is effective for the prevention of recurrence of Crohn's disease after ileocolonic resection.     

Role of capsule endoscopy in inflammatory bowel disease: where we are and where we are going

Capsule endoscopy (CE) is an innovative technological breakthrough that for the first time provides a noninvasive method to obtain high-resolution imaging of the entire small bowel. Since its recent inception, the diagnostic utility of CE has become well established for the evaluation of diverse ulcerative and inflammatory disorders of the jejunum and ileum. The incredible resolution of its lens (0.1 mm) detects focal villous edema or atrophy, denuded, as well as ulcerated mucosal lesions missed by other imaging techniques. CE has been shown by meta-analysis to be a more sensitive method to investigate patients for small bowel Crohn's disease, with an incremental yield above 30% versus other imaging modalities. In patients with indeterminate colitis, CE is useful in distinguishing between ulcerative and Crohn's colitis. Among patients with established Crohn's disease, CE may be employed to determine: (1) the extent and severity of small bowel involvement, (2) postoperative recurrence, (3) post-therapy mucosal healing, and (4) whether active small bowel inflammatory lesions exist in the clinical setting of functional bowel disorder. Complications are rare and include capsule retention at stricture sites. The new patency capsule can diminish the risk of the latter problem in at-risk patients. CE can also serve as a guide to sites that require biopsies or dilatation by push or double-balloon enteroscopy. However, other causes of small bowel lesions may mimic Crohn's disease. A standard terminology system has thus been developed, and a CE Crohn's disease severity scoring index is currently undergoing validation studies.     

Postoperative recurrence of Crohn's disease in relation to radicality of operation and sulfasalazine prophylaxis: a multicenter trial

Recurrence rate is high after operation for Crohn's disease. A multicenter trial was performed to study the effect of radical or nonradical operation and of sulfasalazine prophylaxis versus placebo on postoperative recurrence rate in 232 patients with Crohn's disease. Sixteen medical and surgical centers participated in the study, 7 operating radically and 9 nonradically. The follow-up period lasted 3 years, the allocation to drug treatment was randomized and double blind. Recurrence was significantly less frequent and occurred later in patients who were operated nonradically. Patients on sulfasalazine prophylaxis had a better prognosis than on placebo. This effect was statistically significant in the first 2 years of treatment. Both strategies were additive: nonradical operation and sulfasalazine had the best prognosis, radical operation and placebo was worst. It is concluded that postoperative recurrence is best prevented by resecting nonradically and prescribing 3 g of sulfasalazine daily at least over 2 years.     

Enterovesical fistulas complicating Crohn's disease: clinicopathological features and management

Enterovesical fistula is a relatively rare condition in Crohn's disease. This study was undertaken to examine clinicopathological features and management of enterovesical fistula complicating Crohn's disease. Thirty patients with enterovesical fistula complicating Crohn's disease, treated between 1970 and 1997, were reviewed. Urological symptoms were present in 22 patients; pneumaturia in 18, urinary tract infection in 7, and haematuria in 2. In 5 patients clinical symptoms were successfully managed by conservative treatment, and they required no surgical treatment for enterovesical fistula. Twenty-five patients required surgery. All the patients were treated by resection of diseased bowel and pinching off the dome of the bladder. No patients required resection of the bladder. The Foley catheter was left in situ for an average of 2 weeks after operation. Three patients developed early postoperative complications; two bowel anastomotic leaks, and one intra-abdominal abscess. All these complications were associated with sepsis and multiple fistulas at the time of laparotomy. After a median follow-up of 13 years, 3 patients having postoperative sepsis (anastomotic leak or abscess) developed a recurrent fistula from the ileocolonic anastomosis to the bladder, which required further surgery. In the other 22 patients without postoperative complications there has been no fistula recurrence. In conclusion, the majority of patients with enterovesical fistula required surgical treatment: resection of the diseased bowel and oversewing the defect in the bladder. The fistula recurrence was uncommon, but the presence of sepsis and multiple fistulas at the time of laparotomy increased the incidence of postoperative complications and fistula recurrence.