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

Effect of resection margins on the recurrence of Crohn's disease in the small bowel. A randomized controlled trial

OBJECTIVE

The authors assess the effect of surgical margin width on recurrence rates after intestinal resection of Crohn's Disease (CD).

BACKGROUND

The optimal width of margins when resecting DC of the small bowel is controversial. Most studies have been retrospective and have had conflicting results.

METHODS

Patients undergoing ileocolic resection for CD (N = 152) were randomly assigned to two groups in which the proximal line of resection was 2 cm (limited resection) or 12 cm (extended resection) from the macroscopically involved area. Patients also were classified by whether the margin of resection was microscopically normal (category 1), contained nonspecific changes (category 2), were suggestive but not diagnostic for CD (category 3), or were diagnostic for CD (category 4). Recurrence was defined as reoperation for recurrent preanastomotic disease.

RESULTS

Data were collected on 131 patients. Median follow-up time was 55.7 months. Disease recurred in 29 patients: 25% of patients in the limited resection group and 18% of patients in the extended resection group. In the 90 patients in category 1 with normal tissue, recurrence occurred in 16, whereas in the 41 patients with some degree of microscopic involvement, recurrence occurred in 13. Recurrence rates were 36% in category 2, 39% in category 3, and 21% in category 4. No group differences were statistically at the 0.01 level.

CONCLUSION

Recurrence of CD is unaffected by the width of the margin of resection from macroscopically involved bowel. Recurrence rates also do not increase when microscopic CD is present at the resection margins. Therefore, extensive resection margins are unnecessary.

The impact of disease pattern, surgical management, and individual surgeons on the risk for relaparotomy for recurrent Crohn's disease

OBJECTIVE

The authors provide a multivariate analysis of a large single-center experience with limited surgery for Crohn's disease.

SUMMARY BACKGROUND DATA

During the past decade, the aim of surgery for Crohn's disease has shifted from radical operation, achieving inflammation-free margins of resection, to "minimal surgery," intended to remove just grossly inflamed tissue or performing strictureplasties.

METHODS

Seven hundred ninety-three cases of resection and/or strictureplasty in 689 individuals with histologically verified Crohn's disease were followed for a mean period of 50 months (range, 5-166 months). Two different end points were analyzed: 1) any relaparotomy for recurrent (or persistent) Crohn's disease and 2) relaparotomy for site-specific recurrence. More than 30 variables of patient/disease characteristics and surgical management were included in a proportional hazard model.

RESULTS

Five parameters were associated independently with the risk for relaparotomy: increased risk coincided with young age at onset of disease, involvement of jejunum, enterocutaneous fistula, or performed strictureplasty, and decreased risk followed ileocecal resection. Site-specific risks of reoperation were calculated on the basis of 1260 intestinal resections or anastomoses performed in these patients. Young age at onset, duodenal and jejunal involvement, presence of enterocutaneous or perianal fistula, and a single surgeon (of 23) were associated significantly with increased risk of regional recurrence but not strictureplasty or inflammation at margins of resection.

CONCLUSIONS

Limited surgery for Crohn's disease is not associated with increased risk of regional recurrence requiring reoperation. However, patients with juvenile onset, proximal small bowel disease, and some types of fistulae are at a considerable risk of experiencing early surgical recurrence.

Prognostic factors for postoperative recurrence of Crohn's disease. Gruppo Italiano per lo Studio del Colon e del Retto (GISC)

Prognostic factors for postoperative recurrence of Crohn's disease (CD) have been widely investigated but not yet clearly identified.

PURPOSE

Aim of this study was, therefore, to analyze the association between demographic, clinical, laboratory, and surgical characteristics of patients and the cumulative probability of endoscopic postoperative recurrence.

METHODS

The study was performed in 110 patients who were enrolled in the Italian multicenter, randomized, controlled trial on the effectiveness of 5-aminosalicylic acid (5-ASA) in the prevention of postoperative recurrence in CD. Patients had undergone their first intestinal resection for CD of the terminal ileum with or without involvement of cecum ascending colon. Recurrence was defined on the basis of endoscopy. The following variables were evaluated as potential prognostic factors: gender, age, years since diagnosis, clinical course (perforative and non-perforative), Crohn's Disease Activity Index score, white blood count, erythrocyte sedimentation rate, C-reactive protein, and orosomucoids assessed before the operation. Timing of operation (elective or urgent), type of anastomosis (end-to-end, end-to-side, side-to-side), and prophylactic treatment were also evaluated. Colon ileoscopy was performed at 6, 12, 24, and 36 months after operation. The association between variables and the cumulative proportion of recurrence was analyzed both by univariate analysis (life table method, log-rank test) and multivariate regression analysis (Cox's model, stepwise procedure).

RESULTS

Results of this study indicate that, of the features considered before surgery, only leukocytosis (white blood count, >9,000 ml) was significantly associated with an increased risk of recurrence (P < 0.05) at univariate analysis. This finding was not confirmed by multivariate analysis. A trend toward a higher risk of recurrence for patients who have had a resection with end-to-end anastomosis compared with those who have had a resection and other types of anastomosis was also observed. This trend reached significantly in the group of patients submitted to treatment with 5-ASA. The multivariate analysis showed that 5-ASA-treated patients with end-to-end had a risk of recurrence more than threefold higher than those with other types of anastomosis (relative risk, 3.40; 95 percent confidence interval, 1.00-11.96; P < 0.03).

CONCLUSIONS

From a practical point of view, it has been estimated that the combination of intestinal resection plus side-to-side or end-to-side anastomosis with oral 5-ASA treatment reduces by 64 percent the postoperative recurrence rate in CD at three years follow-up.

Prophylactic mesalamine treatment decreases postoperative recurrence of Crohn's disease

BACKGROUND & AIMS

Recurrence of Crohn's disease frequently occurs after surgery. A randomized controlled trial was performed to determine if mesalamine is effective in decreasing the risk of recurrent Crohn's disease after surgical resection is performed.

METHODS

One hundred sixty-three patients who underwent a surgical resection and had no evidence of residual disease were randomized to a treatment group (1.5 g mesalamine twice a day) or a placebo control group within 8 weeks of surgery. The follow-up period was a maximum of 72 months.

RESULTS

The symptomatic recurrence rate (symptoms plus endoscopic and/or radiological confirmation of disease) in the treatment group was 31% (27 of 87) compared with 41% (31 of 76) in the control group (P = 0.031). The relative risk of developing recurrent disease was 0.628 (90% confidence interval, 0.40-0.97) for those in the treatment group (P = 0.039; one-tail test) using an intention-to-treat analysis and 0.532 (90% confidence interval, 0.32-0.87) using an efficacy analysis. The endoscopic and radiological rate of recurrence was also significantly decreased with relative risks of 0.654 (90% confidence interval, 0.47-0.91) in the effectiveness analysis and 0.635 (90% confidence interval, 0.44-0.91) in the efficacy analysis. There was only one serious side effect (pancreatitis) in subjects in the treatment group.

CONCLUSIONS

Mesalamine (3.0 g/day) is effective in decreasing the risk of recurrence of Crohn's disease after surgical resection is performed.

Construction of a new intestinal valve

PURPOSE

A surgical technique is presented which creates an intestinal valve.

METHODS

In six dogs, the terminal ileum and the ascending colon were removed and the valve was made. The valve has been constructed in eight humans, three of them were cases of short bowel syndrome with resection of the ileocecal valve and five cases were right hemicolectomies attributable to a carcinoma of the cecum and ascending colon.

RESULTS

The dogs were observed for a period of four to six months, during which time the animals stayed healthy. In the cases of short bowel syndrome in humans, the valve reduced the number of evacuations, in the five cases of right hemicolectomies the evolution was without complications.

CONCLUSION

This surgical technique can be useful in the management of patients with morbidity by resection of the ileocecal valve.

Prediction of early symptomatic recurrence after intestinal resection in Crohn's disease

OBJECTIVE

This study was performed to identify clinical criteria that may help recognize patients with Crohn's disease who are at high risk for early symptomatic postoperative recurrence.

SUMMARY BACKGROUND DATA

Currently, no reliable criteria are available to help recognize patients who are prone to experience early symptomatic recurrence.

METHODS

One hundred sixty-four patients undergoing intestinal resection for Crohn's disease at the Mount Sinai Hospital between 1976 and 1989 were studied prospectively. Patients with symptomatic recurrent disease within 36 months were defined as having an early recurrence.

RESULTS

Multivariate analysis revealed that the number of anastomoses was the most important prognostic indicator (p = 0.001), followed by inflammation at the resection margins (p < 0.05). Patients requiring an ileostomy had a significantly lower early recurrence rate than those having single or multiple anastomoses. There was no significant correlation between inflammation at the margins and early recurrence in patients requiring an ileostomy (n = 38), or a single anastomosis (n = 98). When the margins were examined in the 28 patients with 2 or more anastomoses, 10 of 11 patients (91%) with inflammation at either margin experienced early recurrence. Patients having multiple anastomoses with normal margins had the same recurrence rate as patients with single anastomosis (42%).

CONCLUSIONS

Patients with extensive Crohn's disease requiring multiple resections with anastomosis, especially when microscopic inflammation is present at the margins, are at very high risk for symptomatic early recurrence. Ileostomy seems to be associated with a significantly lower early recurrence potential than anastomosis. Further study is needed to determine whether avoidance of multiple anastomosis and adjuvant medical treatment can alter the course of the disease after intestinal resection in patients at high risk for early symptomatic recurrence.