Surgical management of Crohn's disease. Influence of disease at margin of resection

Recurrence rate after surgical treatment of Crohn's disease

In an unselected series of 207 consecutive patients with Crohn's disease diagnosed between 1958 and 1974, 170 underwent a resection of all the macroscopically involved bowel ('radically' resected). Two patients died during the first postoperative month. The crude recurrence rate for the surviving 168 patients was 49%. The cumulative recurrence rate, calculated by the actuarial method, was 53% at 15 years. Age, sex, length of preoperative disease history, localization of the lesions in the bowel, and primary surgical procedures performed had no influence on the recurrence rate. However, the histopathological appearance of the resection margins seemed to influence the prognosis, since the presence of ulcers and/or granulomas was correlated with a significantly increased recurrence rate.

Risks of intestinal cancer in Crohn's disease

This review describes the principal features of the three studies that have established clearly that patients in the U.S.A. or the U.K. who have long-standing (greater than 7 years) Crohn's colitis are at increased risk (up to 20-fold) of developing large bowel cancer. In addition, it emphasizes that there are no data on the extent of this risk in patients in other countries, and also that the magnitude of the risk of cancer of the small intestine in Crohn's disease is unknown. Despite the increased incidence of large bowel cancer in long-standing Crohn's colitis in the U.S.A. or the U.K., the total number of such patients is small, as is the number in which the colonic carcinoma will occur. However, careful supervision is advised for the small group at risk, despite the limitations of current methods for the early detection of cancer of the large intestine.

The influence of disease at the margin of resection on the outcome of Crohn's disease

Sixty-seven patients with Crohn's disease undergoing 81 resections followed by a restorative procedure were reviewed to evaluate the influence of microscopic disease at the margin of resection on the recurrence rate. The average follow-up after resection was 5.6 +/- 2.8 years. The resectional margins were classified into three groups depending on the microscopic appearance of the most involved margin. Recurrent disease developed in 36 per cent of the resections without microscopic evidence of Crohn's disease, while 38 per cent of the resections with signs of Crohn's disease developed a clinical recurrence. The recurrence rate increased with the follow-up time, but was independent of microscopical disease at the resectional margins. Therefore we recommend restricted resection of macroscopically diseased bowel. Microscopical involvement does not seem to increase the recurrence rate.

Management of enterocutaneous fistulae in Crohn's disease

The outcome among 39 patients with enterocutaneous fistulae complicating Crohn's disease has been reviewed. The patients were considered in two groups: (1) no disease - all were early postoperative fistulae (n = 9); (2) active disease (i) without abscess formation (n = 16), (ii) with abscess formation (n = 14). Postoperative fistulae with no evidence of active Crohn's disease healed spontaneously. Fistulae in the presence of active disease did not heal even with prolonged medical management. The only effective treatment was excision of the diseased segment from which the fistulae arose and any distal obstruction. None of the fistulae closed surgically has recurred.

The importance of disease-free margins in resections for Crohn's disease

It has long been a fundamental principle of surgical therapy for Crohn's disease to remove all disease prior to doing an anastomosis. The authors recently noted with concern an article describing a series of patients demonstrating that residual involvement of anastomotic microscopic disease had no significant effect on the recurrence rate at the anastomosis. Examining their own series of 710 patients undergoing surgery for Crohn's disease, the authors found 42 patients with residual anastomotic disease. The criteria for involvement were more specific than that used in the above article and included microscopic mucosal disease. The recurrence rate within the follow-up period of eight years in patients with only microscopic involvement was 89.4 per cent. This was significantly higher than the institutional recurrence rate for Crohn's resections, previously reported, of 55 per cent at ten years. The authors feel that clear margins should be obtained in resections for Crohn's disease, if at all feasible.

The long-term outcome of restorative operation in Crohn's disease: influence of location, prognostic factors and surgical guidelines

The course of all 113 patients with Crohn's disease whose initial procedure involved an anastomosis operated upon from 1942 to 1972 was followed through 1980. The calculated cumulative 30-year total mortality was 23.4%, 16.7% disease-related. The cumulative recurrence rate was 29% at five years, 52% at ten years, 64% at 15 years and 84% at 25 years, with no important differences between disease locations and types of operation. Sex, age, duration, granulomas, enteral or perirectal fistulas and length of the resection, the disease, and the proximal resection margin had no significant influence on the rates of development of recurrent disease or on functional outcome. By far the most common site of recurrence was the neo-terminal ileum, but in ileocolitis compared with ileitis, recurrence was 5.2 times more likely (p = 0.0001) to involve the adjacent or remote colon as well. Moreover, only 1/63 ileitis patients eventually required ileostomy, whereas 15/47 patients with ileocolitis or colitis ultimately required this procedure (p less than 0.001). The current status of the patients was excellent or good in 64% and unwell or dead related in 24%. Urolithiasis developed in 19%.