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

Macroscopic pathology and all that: a personal view

I hope that this treatise adds to the excellent reviews by Varma and colleagues, emphasising the importance of accurate macroscopic assessment and report provision. I have especially highlighted the importance of not divorcing the clinical data and the macroscopic analysis from the microscopic assessment as all are required to provide an accurate and cogent overall composition. The review has also identified areas where the evolution of pathological practice has gone a little awry and requires to be modified and/or justified with evidence base. There is also an emphasis on block economy, as there is no doubt that considerable savings can be made if more attention is paid to more judicious block selection. It is also commended that subspecialties other than gastrointestinal pathology introduce reporting quality standards, like lymph node harvest numbers and other important prognostic and management indicators, to improve the quality of macroscopic pathology worldwide to the benefit of our service users and their patients.

Positive margins and plexitis increase the risk of recurrence after ileocecal resection: A systematic review and meta-analysis

INTRODUCTION

There is debate over the impact of residual microscopic disease after ileocecal resection in Crohn's disease (CD) to predict recurrence. We conducted a meta-analysis to evaluate the impact of positive histological margins and plexitis after ileocecal resection on the risk of postoperative recurrence.

METHODS

Using a systematic search, we identified. 30 studies evaluating the impact of inflammatory margins on CD recurrence. The primary outcome was the postoperative clinical recurrence and secondary outcomes were surgical, and endoscopic recurrence. We performed random-effects meta-analysis and estimated odds ratio (OR) and 95% CIs.

RESULTS

Thirty studies were analyzed, seven focused on myenteric plexitis, six on submucosal plexitis and twenty-three on positive margins. Inflammatory margins were associated with a higher rate of clinical and surgical recurrences: respectively 14 studies - OR 2.38; 95% CI, 1.54 - 3.68- I2 = 68.2%, Q test-p = 0.0003 and 8 studies - OR, 1.52; 95% CI, 1.07-2.16 - I2 =0%; Q test-p = 0.43. The presence of myenteric plexitis was associated with a higher rate of clinical recurrence (4 studies- OR, 1.60; 95%CI, 1.12-2.29; I2= 0%, Q-test-p = 0.61), and of endoscopic recurrence (4 studies - OR, 4.25; 95%CI; 2.06-8.76; I2= 0%, Q test-p = 0.97). Submucosal plexitis was not associated with an increased risk of endoscopic recurrence (4 studies - OR, 0.94; 95%CI; 0.58-1.52; I2= 0%, Q test-p = 0.79).

CONCLUSION

Inflammatory margins and/or plexitis were associated with postoperative recurrence after ileocecal resection for CD. These elements should be taken into account in future algorithm for prevention of postoperative recurrence.

Does microscopic involvement of the surgical margins after ileocecectomy in Crohn's patients predict early recurrence?

OBJECTIVE

The primary aim of this study was to determine whether the microscopic presence of Crohn's disease (CD) in the resected specimen margins in patients undergoing ileocecectomy predicts disease recurrence. The secondary aim was to identify other risk factors which can predict recurrence.

METHODS

All CD patients who underwent ileocecectomy in a single colorectal unit between 2000 and 2015 were retrospectively evaluated. The diagnosis of CD and margin involvement status were retrieved from pathology reports. Recurrence was determined according to medical records or via a telephone questionnaire. Demographic, clinical, and surgical parameters were compared between patients with and without histopathologic evidence of CD in the resected margins.

RESULTS

A total of 202 CD patients were included, 49 with and 153 without evidence of microscopic involvement in the resected margins. The main demographic characteristics, surgical approach and procedure, and postoperative course, including medical treatment, clinical or endoscopic recurrence, and reoperation rates, were similar for both groups. Patients who were operated laparoscopically (n=58, p 0.016), conversion from laparoscopic to open (n=25, p 0.016), stapled anastomosis (n=150, p 0.004), when stricturoplasty was required (n=12, p 0.046), and those with perianal disease (n=32, p 0.045) had shorter time to recurrence. Male gender had increased hazard ratio (n=106, HR 1.38) for reoperation, but not significantly (p=0.058).

CONCLUSIONS

The presence of microscopic CD at the resected specimen margins was not associated with the risk of disease recurrence. Other demographic, clinical, and technical features that did correlate with early recurrence were identified. These results support a conservative approach to the extent of resection in CD patients undergoing ileocecectomy.

TRIAL REGISTRATION

Not relevant.

Positive histologic margins is a risk factor of recurrence after ileocaecal resection in Crohn's disease

INTRODUCTION

Surgical resection is not curative in Crohn's disease (CD) and, recurrence after surgery is a common situation. The identification of patients at high risk of recurrence remains disappointing in clinical practice.

OBJECTIVE

To evaluate the impact of residual microscopic disease on margins on the risk of recurrence after ileocaecal resection in CD.

PATIENTS AND METHODS

All patients who underwent ileocaecal resection between January 1992 and December 2016 were prospectively identified. Demographic data, clinical, surgical and histological variables were retrospectively collected. Positive histologic margin was assessed prospectively and defined by the presence of acute inflammatory lesions on margins: erosion, ulceration, chorion infiltration by neutrophils, cryptic abscesses or cryptitis.

RESULTS

One hundred twenty five patients were included, with a median follow-up of 8 years (Interquartile Range (IQR), 4.3-15.2). Half (49.6%, n = 62) were women, and the median age at surgery was 33 years (IQR, 24-42). Fifty-six (44.8%) had positive inflammatory margins. Five years after surgery, respectively 29 (51%) and 23 (34%) patients with positive and negative margins had clinical recurrence (p = 0.034). At the end of the follow-up, respectively 60% (n = 34) and 47% (n = 33) patients had clinical recurrence (p = 0.07). CD-related hospitalizations were observed in respectively 37.5% (n = 21) and 18.8% (n = 13) with positive and negative margins (p = 0.02). Fourteen patients (25%) with positive intestinal margins had surgical recurrence at the end of the follow-up compared to 5 patients (7%) with negative margins (p = 0.04). Multivariate analysis confirmed that positive intestinal margin was independently associated with surgical recurrence (OR, 4.7 (CI95%, 1.4-15.3), p = 0.01).

CONCLUSION

Positive histologic margin was associated with an increased risk of clinical and surgical recurrence after ileocaecal resection for Crohn's disease.

Active Margins, Plexitis, and Granulomas Increase Postoperative Crohn's Recurrence: Systematic Review and Meta-analysis

BACKGROUND & AIMS

Rates of postoperative Crohn's disease recurrence remain high, although the ability to predict this risk of recurrence remains limited. As such, we aimed to determine the association of histologic features at the time of resection with postoperative recurrence.

METHODS

Electronic databases were searched through February 2020 for studies that reported risk of clinical, endoscopic, or surgical postoperative recurrence in patients with positive resection margins, plexitis, or granulomas in the index specimen. Pooled risk ratios (RRs) with 95% CIs were calculated for this risk in patients with and without these histologic features.

RESULTS

Twenty-one studies (2481 patients) assessed positive resection margins, 10 studies (808 patients) assessed plexitis, and 19 studies (1777 patients) assessed granulomas. Positive resection margins increased the risk of clinical (RR, 1.26; 95% CI, 1.06-1.49; I² = 41%) and surgical (RR, 1.87; 95% CI, 1.14-3.08; I² = 71%) recurrence, with a trend toward endoscopic recurrence (RR, 1.56; 95% CI, 0.79-3.05; I² = 85%). Granulomas increased the risk of clinical (RR, 1.31; 95% CI, 1.05-1.64; I² = 36%) and endoscopic (RR, 1.37; 95% CI, 1.00-1.87; I² = 49%) recurrence, with a trend toward surgical recurrence (RR, 1.58; 95% CI, 0.89-2.80; I² = 75%). Plexitis increased the risk of endoscopic recurrence (RR, 1.31; 95% CI, 1.00-1.72; I² = 20%), with a trend toward clinical recurrence (RR, 1.34; 95% CI, 0.95-1.91; I² = 46%).

CONCLUSIONS

Positive resection margins, granulomas, and plexitis are predictive of postoperative Crohn's disease recurrence and should be recorded at the time of index resection.

Clinical Features of Intra-Abdominal Abscess and Intestinal Free-Wall Perforation in Korean Patients with Crohn's Disease: Results from the CONNECT Study

Background: In Crohn's disease (CD), intra-abdominal abscess (IA) and intestinal free-wall perforation (IP) have a common mechanism of transmural inflammation; however, their manifestation is different. Objective: This study aimed to investigate differences in the clinical features between IA and IP in Korean patients with Crohn's disease. Design: A retrospective cohort study. Setting: Thirty university hospitals and two local hospitals in Korea. Patients: Patients who were diagnosed with CD between July 1982 and December 2008 were enrolled. Main Outcome Measures: Clinical characteristics of IA and IP. Results: Among 1286 patients with CD, 147 (11.4%) had IA and 83 (6.5%) had IP. IA patients were younger than those of IP (24.2 ± 8.6 vs. 30.4 ± 11.1 years, p = 0.001). Location and behavior were significantly different between IA and IP (p = 0.035 and 0.021). In multivariate analyses, perianal fistula was not associated with increased risk of IA and IP, while intestinal stricture was associated with increased risk of IA (OR: 2.72, p < 0.0001) and IP (OR: 2.76, p < 0.0001). In subgroup analyses, 55 (36.5%) IA patients were diagnosed at the diagnosis of CD, and 92 (63.5%) during follow-up of CD, while 47 (56.6%) IP patients were diagnosed at the diagnosis of CD, and 36 (43.3%) during follow-up of CD. Conclusions: There are several differences in the clinical features of IA and IP in Korean patients with CD. The development mechanism is considered as identical, but further investigation should be needed for clinical implication.

The Predictive Value of Inflammation at Ileocecal Resection Margins for Postoperative Crohn's Recurrence: A Cohort Study

BACKGROUND

Resections for Crohn's disease should be limited and only resect macroscopically affected bowel. However, recent studies suggest microscopic inflammation at resection margins as a predictor for postoperative recurrence. The clinical impact remains unclear, as non-uniform pathological criteria have been used. The aim of this study was to assess the predictive value of pathological characteristics at ileocecal resection margins for recurrence.

METHODS

Both resection margins of 106 consecutive patients undergoing ileocecal resection for Crohn's disease between 2002 and 2009 were revised and scored for active inflammation, myenteric plexitis, and granulomas. Pathological findings were correlated to recurrence, defined as recurrent disease activity demonstrated by endoscopy (modified Rutgeerts score ≥i2) requiring upscaling medical treatment, using multivariate analysis.

RESULTS

Active inflammation was found at the proximal and distal resection margin in 27% and 15% of patients, respectively, myenteric plexitis in 37% and 32%, respectively, and granulomas in 4% and 6%, respectively. In total, 47 out of 106 patients developed recurrence. Only active inflammation at the distal colonic resection margin was an independent significant predictor for recurrence (88% vs 43% vs 51% for distal, proximal, and no involved margins, respectively; P < 0.01).

CONCLUSION

Active inflammation at the distal colonic resection margin after ileocecal resection identifies a patient group at high risk for postoperative recurrence both at the anastomotic site and the colon because it identifies undiagnosed L3 disease. These patients have a different and more aggressive natural history and require more intense medical treatment. Therefore, pathological evaluation of the distal resection margin should be implemented in daily practice.

Transmural Histological Scoring Systems in Crohn's Disease: A Systematic Review With Assessment of Methodological Quality and Operating Properties

BACKGROUND

The relative proportion of inflammation and fibrosis in a stricture is highly relevant in defining the clinical approach for Crohn's disease [CD] patients. Whereas transmural inflammation in CD can be accurately estimated by cross-sectional imaging, evaluating the extent and severity of fibrosis still requires surgical pathology of intestinal resection specimens. This study systematically reviewed all existing transmural histopathological scoring systems developed for the assessment of inflammation and/or fibrosis in CD.

METHODS

A systematic review of histopathological scoring systems for the assessment of transmural inflammation and/or fibrosis in CD, focusing on originally developed scoring systems. Risk of bias, methodological quality, and operating or psychometric properties [validity, reliability, responsiveness, and feasibility] of each histological scoring system were analysed.

RESULTS

A total of 29 original scoring systems were included in this review. Three scoring systems were highlighted as the most widely reproduced, one aimed at assessing inflammation only and two aimed at assessing inflammation and fibrosis. These scores were more widely reproduced probably due to their ease of application in clinical studies. Two highly comprehensive scores were identified, showing good operating properties and high methodological quality, as well as the lowest risk of bias; these should, therefore, be further validated in clinical research studies.

CONCLUSIONS

This study reviewed all existing transmural histopathological scoring systems for the assessment of inflammation and/or fibrosis in CD and identified the most reliable and accurate scores for clinical research and clinical practice settings.

Anastomotic Ulcers After Ileocolic Resection for Crohn's Disease Are Common and Predict Recurrence

BACKGROUND

Crohn's disease recurrence after ileocolic resection is common and graded with the Rutgeerts score. There is controversy whether anastomotic ulcers represent disease recurrence and should be included in the grading system. The aim of this study was to determine the impact of anastomotic ulcers on Crohn's disease recurrence in patients with prior ileocolic resections. Secondary aims included defining the prevalence of anastomotic ulcers, risk factors for development, and their natural history.

METHODS

We conducted a retrospective cohort study of patients undergoing an ileocolic resection between 2008 and 2017 at a large academic center, with a postoperative colonoscopy assessing the neoterminal ileum and ileocolic anastomosis. The primary outcome was disease recurrence defined as endoscopic recurrence (>5 ulcers in the neoterminal ileum) or need for another ileocolic resection among patients with or without an anastomotic ulcer in endoscopic remission.

RESULTS

One hundred eighty-two subjects with Crohn's disease and an ileocolic resection were included. Anastomotic ulcers were present in 95 (52.2%) subjects. No factors were associated with anastomotic ulcer development. One hundred eleven patients were in endoscopic remission on the first postoperative colonoscopy. On multivariable analysis, anastomotic ulcers were associated with disease recurrence (adjusted hazard ratio [aHR] 3.64; 95% CI, 1.21-10.95; P = 0.02). Sixty-six subjects with anastomotic ulcers underwent a second colonoscopy, with 31 patients (79.5%) having persistent ulcers independent of medication escalation.

CONCLUSION

Anastomotic ulcers occur in over half of Crohn's disease patients after ileocolic resection. No factors are associated with their development. They are associated with Crohn's disease recurrence and are persistent.

Meta-analysis of Histological Margin Positivity in the Prediction of Recurrence After Crohn's Resection

BACKGROUND

Despite significant advances in the medical management of Crohn's disease, many patients will require intestinal resection during their lifetime. It is disappointing that many will also develop disease recurrence.

OBJECTIVES

The current study utilizes meta-analytical techniques to determine the effect of positive histological margins at the time of index resection on disease recurrence.

DATA SOURCES

Embase, Medline, PubMed, PubMed Central, and Cochrane databases were searched using a Boolean search algorithm for articles published up to August 2017.

STUDY SELECTION

Meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

MAIN OUTCOME MEASURES

Databases were searched for studies reporting the outcomes for patients with Crohn's disease undergoing primary resection that correlated resection margin status with disease recurrence. Results were reported as pooled ORs with 95% CI.

RESULTS

A total of 176 citations were reviewed; 18 studies comprising 1833 patients were ultimately included in the analysis, with a mean rate of histopathological margin positivity of 41.7 ± 17.4% and a pooled mean follow-up of 69 ± 39 months. Histopathological margin positivity was associated with a higher rate of overall recurrence (OR, 1.7; 95% CI, 1.3-2.1; p < 0.001), clinical recurrence (OR, 1.7; 95% CI, 1.0-2.8; p = 0.04), and anastomotic recurrence (OR, 1.6; 95% CI, 1.0-2.3; p = 0.03). In studies reporting plexitis specifically at the resection margin, there was an increase in recurrence (OR, 2.3; 95% CI, 1.1-4.9; p = 0.02).

LIMITATIONS

The definitions of histological margin positivity and postoperative recurrence vary between the studies and follow-up durations vary.

CONCLUSIONS

The presence of involved histological margins at the time of index resection in Crohn's disease is associated with recurrence, and plexitis shows promise as a marker of more aggressive disease. Further studies with homogeneity of histopathological and recurrence reporting are required.

Novel Approaches to Ileocolic and Perianal Fistulising Crohn's Disease

Crohn's disease (CD) is a well-known idiopathic inflammatory bowel disease characterised by transmural inflammation which can ordinarily affect all the gastrointestinal tract. Its true aetiology is unknown, and a causal therapy is not available to date. The most peculiar aspect of CD lies in its absolute heterogeneity, as we might face various scenarios, locations of the disease, pathologic behaviours, and severity of the disease itself. For these reasons, the cornerstone for the treatment of CD lies in a complex multimodal management, requiring close collaborations among surgeons, gastroenterologists, radiologists, and staff nurses. Advances in surgical and medical therapy are changing the course of the disease. Nowadays, the introduction of both laparoscopy and novel surgical techniques, the improvement of recovery pathways, and the opening of new frontiers are allowing healthcare professionals to deal with complex and recurrent scenarios, trying to spare bowel and anal function, thus ensuring a better quality of life for the patient. Given the heterogeneity and complexity of this disease, it would be impractical to encompass all the aspects of surgical management of CD. This review will address areas that are considered to be hot topics, controversies, challenges, and novelties: thus, we will focus on complex ileocecal disease, surgical strategies, and fistulising perianal conditions.

Increased enteric glial cells in proximal margin of resection is associated with postoperative recurrence of Crohn's disease

BACKGROUND AND AIM

The enteric nervous system can amplify or modulate intestinal inflammation through secretion of neuropeptides, and enteric glial cells have been implicated in the pathophysiology of Crohn's disease. The goal of the study was to search for an association between the density of neurons, neuropeptides, and enteric glial cells and postoperative recurrence.

METHODS

The ileal proximal uninflamed section from ileocolonic sample was studied using immunohistochemistry with antibodies directed against vasoactive intestinal polypeptide (VIP), substance P (SP), neuron-specific enolase (NSE), and the glial marker protein S100. The density in the submucosa was calculated, and the relationship of the density of VIP, SP, NSE, and S100 and postoperative disease recurrence was assessed.

RESULTS

There were no significant differences between patients with and without postoperative endoscopic recurrence or clinical recurrence for the density of NSE-positive, VIP-positive, or SP-positive neurons in the proximal margin. Interestingly, the density of S100-positive enteric glial cells was significantly increased in patients with endoscopic and clinical recurrence than in subjects without disease recurrence (P ˂ 0.001). The density of S100-positive enteric glial cells was independently associated with postoperative disease recurrence.

CONCLUSIONS

Increased S100-positive enteric glial cells are associated with a high risk of both endoscopic and clinical recurrence after surgery. These findings have implications in individualized postoperative prophylaxis for Crohn's disease.

Bowel perforation in Crohn's Disease: correlation between CDAI and Clavien-Dindo scores

BACKGROUND

Many studies have elaborated different kind of activity indices for Crohn's Disesase (CD) with the endpoint of univocally measure and evaluate the gravity of its lesions and symptoms.

AIM

Purpose of this work is to study and define the correlation that runs between the preoperative score obtained at the Crohn's Disease Activity Index, the occurrence of postoperative complications that will require re-intervention and the severity of the postoperative lesions evaluated using the Clavien-Dindo score.

PATIENTS AND METHODS

We have collected and analyzed data from 23 patients (12 males, 11 females) that in a period that spans from 2010 to 2016 had been recovered in our Operative Unit and then undergone surgical treatment for the perforative complications of the CD.

RESULTS

The CDAI scores obtained for each patient and the data concerning their postoperative period have been analyzed using the ANOVA system. Results demonstrate the existence of a statistically signifying correlation (p = 0.0016) between the mean category's CDAI score and the Clavien-Dindo classification.

CONCLUSIONS

Despite the small number of patients that had been recruited and analyzed in our study, it clearly shows a statistically signifying correlation between CDAI scores higher than 150 points and the risk of occurrence of severe postoperative complications in patients that had been subjected to surgical procedures for perforative or abscessual complications in Crohn's Disease.

Sphincter-sparing intersphincteric rectal resection as an alternative to proctectomy in long-standing fistulizing and stenotic Crohn's proctitis?

PURPOSE

Long-standing fistulizing and stenotic proctitis (LFSP) in Crohn's disease (CD) indicates the end stage of the disease. Definitive diversion such as proctectomy is considered to be the only surgical option. The impact of intersphincteric sphincter-sparing anterior rectal resection (IAR) as an alternative to proctectomy is unclear. The aim of this study was to evaluate feasibility, morbidity, outcome, and quality of life (QL) in patients with LFSP undergoing intended IAR.

PATIENTS AND METHODS

Out of a single institution database, 15 patients with LFSP intended for surgery from 856 patients with CD were selected for follow-up analyses.

RESULTS

In 12/15 cases, IAR was carried out while 3/15 patients underwent primary proctectomy due to malignancy (n = 2) or due to patient's wish (n = 1). In one case, IAR revealed unexpected malignancy, which led to secondary proctectomy. In patients with IAR, complete healing of fistulas and stenosis was observed in 46% (n = 5) while 36% (n = 4) of patients showed relapse of fistula and 18% (n = 2) developed restenosis. Ileostomy closure was performed in seven patients from which six patients remained stoma free. QL and fecal incontinence measured by standardized scoring systems were unchanged while stool frequency was reduced after IAR in patients with ileostomy closure. The rate of malignancy in this cohort was 20% (n = 3).

CONCLUSION

LFSP in CD was associated with 20% of malignant transformation. Although IAR fails to improve QL, it is a suitable procedure for the treatment of fistulas and stenosis associated with acceptable healing rates and can avoid a permanent stoma.

Multidisciplinary management of gastrointestinal fibrotic stenosis in Crohn's disease

Crohn's disease (CD) is a chronic inflammatory bowel disease that can involve virtually any part of the gastrointestinal tract. CD complications are the main indications for surgery. A large proportion of these interventions are due to stricturing disease. Although immunosuppressive treatments have been used more frequently during the last 25 years, there is no significant decrease in the need for surgery in patients with CD. Unfortunately, surgery is not curative, as the disease ultimately reoccurs in a substantial subset of patients. To best identify the patients who will require a specific treatment and to plane the most appropriate therapeutic approach, it is important to precisely define the type, the size, and the location of CD stenosis. Diagnostic approaches aim to distinguish fibrotic from inflammatory strictures. Medical therapy is required for inflammatory stenosis. Mechanical treatments are required when fibrotic CD strictures are symptomatic. The choice between endoscopic balloon dilation, stricturoplasty, and laparoscopic or open surgery is based on the presence of perforating complications, the remaining length of small bowel, and the number and length of strictures. The non-hierarchical decision-making process for the treatment of fibrotic CD therefore requires multidisciplinary clinical rounds with radiologists, gastroenterologists, interventional endoscopists, and surgeons.

Histologic features predicting postoperative Crohn's disease recurrence

Recurrence of Crohn's disease (CD) after ileal or colonic resection is common. Many studies have tried to identify predictors of postoperative recurrence (POR) in CD. A wide range of histologic features have been identified, but for most of them, the literature provided conflicting data. In last years, several studies have suggested that histologic findings including inflammatory changes within the enteric nervous system of the resection margin may be associated with CD recurrence. Herein, after briefly summarizing pathophysiology of POR, we review all histological features that have been studied so far: granulomas, histologic appearance at the margin of resection, plexitis, lymphatic vessel density in proximal margin of resection, and morphological analysis of Paneth cells. Granulomas and chronic inflammation at the margin of resection do not seem to predict POR in CD. Active disease at the margin of resection, plexitis, lymphatic vessels density, morphological analysis of Paneth cells may predict POR. Most of these histological features await replication in independent studies. Available evidence indicates that histological findings may be taken into account when developing strategies aimed at preventing postoperative CD recurrence.

Crohn's disease complicated by strictures: a systematic review

The occurrence of strictures as a complication of Crohn's disease is a significant clinical problem. No specific antifibrotic therapies are available. This systematic review comprehensively addresses the pathogenesis, epidemiology, prediction, diagnosis and therapy of this disease complication. We also provide specific recommendations for clinical practice and summarise areas that require future investigation.

Positive histological inflammatory margins are associated with increased risk for intra-abdominal septic complications in patients undergoing ileocolic resection for Crohn's disease

BACKGROUND

Rates of postoperative complications are particularly high among patients with Crohn's disease.

OBJECTIVE

The aim of this study was to assess whether positive inflammatory histological margins, among other factors, pose a risk for intra-abdominal septic complications in patients with Crohn's disease undergoing ileocolic resection.

DESIGN

A retrospective study of patient records, during 2000-2010, was conducted.

SETTINGS

This investigation was performed at a single medical center.

PATIENTS

Included were 166 individuals with Crohn's disease (85 males, mean age 35.6).

INTERVENTION

Ileocolic resection with primary anastomosis was performed.

MAIN OUTCOME MEASURE

The primary outcomes measured were postoperative intra-abdominal septic complications.

RESULTS

Twenty-five patients (15%) developed intra-abdominal septic complications, including anastomotic leak, intra-abdominal abscesses and collections, and enterocutaneous fistulas. There were no postoperative deaths. Univariate analysis revealed that a long course of disease before surgery, an emergency surgery, steroid treatment of more than 3 months before surgery, additional sigmoidectomy, and positive surgical margins detected on histopathological examination were associated with intra-abdominal septic complications. In a multivariate analysis, only disease duration longer than 10 years (OR 4.575 (CI 1.592-13.142), p = 0.005), additional sigmoidectomy (OR 5.768 (CI 1.088-30.568), p = 0.04), and positive histological resection margins (OR 2.996 (CI 1.085-8.277), p = 0.03) were found to be independent risk factors.

LIMITATIONS

This study was limited by the incomplete data regarding preoperative albumin levels.

CONCLUSIONS

Positive histological margins, disease duration of more than 10 years, and added sigmoidectomy are independent risk factors that are associated with postoperative intra-abdominal septic complications in patients undergoing ileocolic resection for Crohn's disease. These risk factors should be considered when the need for a diverting stoma is questionable. A frozen section of the margins may assist in the decision as to a temporary ileostomy construction.

Comparison of strictureplasty and endoscopic balloon dilatation for stricturing Crohn's disease--review of the literature

BACKGROUND

Stricturing Crohn's disease is accompanied by a high-risk for bowel resection and subsequent short bowel syndrome. Strictureplasty (SP) and endoscopic balloon dilatation (EBD) have been developed to prevent, or at least delay, the requirement for resection. The goal of this study was to compare the outcome of these two procedures with regard to complications and disease recurrence.

METHODS

We conducted a MEDLINE literature search to give a current overview about the safety and efficacy of EBD and SP.

RESULTS

The initial search yielded 744 articles. Case reports, reviews and meta-analyses were excluded. Finally, 63 articles (SP, 40 articles; EBD, 23 articles) were used for the review. None of the studies compared the two methods directly. A total of 2,532 patients (SP, n = 1,958; EBD, n = 574) were included. The incidence of perioperative complications after SP was 11% and the incidence of major complications was 5%. The median surgical recurrence rate was 24% after a median follow-up of 46 months. The median technical success for EBD was 90%. Major complications occurred in 3% of the cases. According to an intention-to-treat protocol, the median surgical recurrence rate was 27.6%. Per-protocol analysis revealed a median surgical recurrence rate of 21.4% after a median follow-up of 21 months.

CONCLUSION

Due to the lack of comparable data, there is currently no reliable information on whether one treatment option is superior to the other. Regarding the limited applicability of EBD in strictures of the small bowel, only a controlled trial would provide evidence as a basis for clinical decision making in CD strictures that are potentially treatable by EBD and SP.

Colonic Crohn's disease

Crohn's disease is an inflammatory disease of the gastrointestinal (GI) tract of uncertain etiology. It can affect any portion of the GI tract, involving the colon in approximately 60% of cases. Diagnosis can be unclear, but suspicion can be raised based upon clinical, endoscopic, and pathologic findings. Initial management is often medical, with surgery reserved for patients with colonic complications of Crohn's disease, such as hemorrhage, fulminant colitis, abscess or fistula, stricture, and malignant transformation. The operative choice and conduct depends upon the clinical presentation and intraoperative findings. The extent of resection is controversial, but segmental resection is appropriate in selected cases.

Meta-analysis of the role of granulomas in the recurrence of Crohn disease

PURPOSE

This study used meta-analytical techniques to compare the recurrence of granulomatous vs nongranulomatous Crohn disease.

METHODS

Comparative studies published between 1954 and 2007 of granulomatous vs nongranulomatous Crohn disease were included. Using a random effects model, end points evaluated were the number of recurrences and reoperations, and the time to recurrence and reoperation, of granulomatous vs nongranulomatous Crohn disease. Heterogeneity was assessed and sensitivity analysis was performed to account for bias in patient selection.

RESULTS

Twenty-one studies (14 nonrandomized retrospective, 7 nonrandomized prospective) reported on 2236 patients with Crohn disease, of whom 1050 (47.0%) had granulomas (granulomatous group) and 1186 (53.0%) had no granulomas (nongranulomatous group). The number of recurrences and reoperations was found to be significantly higher in the granulomatous group compared to the nongranulomatous group (odds ratio 1.37, P = .04; odds ratio 2.38, P < .001; respectively), with significant heterogeneity between studies (P = .06; P < .001; respectively). The time to recurrence and reoperation was significantly shorter in the granulomatous group compared with the nongranulomatous group (hazard ratio 1.63, P = .001; hazard ratio 1.62, P = .002; respectively), with no significant heterogeneity between studies. The number of recurrences and reoperations remained significantly higher in the granulomatous group compared to the nongranulomatous group during sensitivity analysis of higher-quality studies, more recent studies, and studies with a larger group of patients.

CONCLUSIONS

Granulomatous Crohn disease appears to be associated with a higher number of recurrences and reoperations and a shorter time to recurrence and reoperation compared to nongranulomatous Crohn disease. Because of significant heterogeneity between studies, further studies should be undertaken to confirm these findings.

Recurrence of Crohn's disease after ileocolic resection is not affected by anastomotic type: results of a multicenter, randomized, controlled trial

PURPOSE

This study attempts to determine whether stapled side-to-side anastomosis, compared with handsewn end-to-end anastomosis, results in decreased recurrence of Crohn's disease following ileocolic resection.

METHODS

Patients with Crohn's disease who underwent an ileocolic resection were randomized to side-to-side anastomosis or end-to-end anastomosis. Colonoscopy was performed at 12 months. The primary outcome was endoscopic recurrence, while the secondary outcome was symptomatic recurrence (defined as symptoms attributable to Crohn's disease and severe enough to warrant treatment, plus endoscopic disease recurrence).

RESULTS

One hundred and thirty-nine subjects were included in the efficacy analysis. After a mean follow-up of 11.9 months, the endoscopic recurrence rate was 42.5 percent in the end-to-end anastomosis group, compared with 37.9 percent in the side-to-side anastomosis group (-4.6 percent difference; 95 percent confidence interval -21.0 to 11.9 percent; P = 0.55). The symptomatic recurrence rate was 21.9 percent in the end-to-end anastomosis group, compared with 22.7 percent in the side-to-side anastomosis group (+0.8 percent difference; 95 percent confidence interval -13.2 to 15.3 percent; P = 0.92). In multivariate logistic regression analysis, previous resections were predictive of a higher risk of both endoscopic (odds ratio 1.78; 95 percent confidence interval 1.06 to 2.90; P = 0.028) and symptomatic (odds ratio 2.0; 95 percent confidence interval 1.14 to 3.60; P = 0.0016) recurrence. Compliance with postoperative maintenance therapy was predictive of a lower risk of symptomatic recurrence (odds ratio 0.13, 95 percent confidence interval 0.01 to 0.78; P = 0.021).

CONCLUSION

Recurrence rates are similar whether end-to-end anastomosis or side-to-side anastomosis is performed.

[Crohn's disease small bowel strictureplasties: early and late results]

BACKGROUND

Strictureplasty is an alternative surgical procedure for Crohn's disease, particulary in patients with previous resections or many intestinal stenosis.

AIM

To analyze surgical complications and clinical follow-up in patients submitted to strictureplasty secondary to Crohn's disease.

METHODS

Twenty-eight patients (57.1% male, mean age 33.3 years, range 16-54 years) with Crohn's disease and intestinal stenosis (small bowel, ileocecal region and ileocolic anastomosis) were submitted to strictureplasty, at one institution, between September 1991 and May 2004. Thirteen patients had previous intestinal resections. The mean follow-up was 58.1 months. A total of 116 strictureplasties were done (94 Heineke-Mikulicz--81%, 15 Finney--13%, seven side-to-side ileocolic strictureplasty--6%). Three patients were submitted to strictureplasty at two different surgical procedures and two in three procedures.

RESULTS

Regarding to strictureplasty, postoperative complication rate was 25% and mortality was 3.6%. Early local complication rate was 57.1%, with three suture leaks (10.7%) and late complication was present in two patients, both with incisional hernial and enterocutaneous fistulas (28.6%). Patients remained hospitalized during a medium time of 12.4 days. Clinical and surgical recurrence rates were 63% and 41%, respectively. Among the patients submitted to another surgery, two patients had two more operations and one had three. Recurrence rate at strictureplasty site was observed in 3.5%, being Finney technique the commonest one. Presently, 19 patients had been asymptomatic with the majority of them under medical therapy.

CONCLUSION

Strictureplasties have low complication rates, in spite of having been done at compromised site, with long term pain relief. Considering the clinical course of Crohn's disease, with many patients being submitted to intestinal resections, strictureplasties should be considered as an effective surgical treatment to spare long intestinal resections.

Strictureplasty vs resection in small bowel Crohn's disease: an evaluation of short-term outcomes and recurrence

AIM

To compare postoperative adverse events and recurrence following strictureplasty or bowel resection in patients with small bowel Crohn's disease (CD).

METHOD

A literature search was performed to identify studies published between 1980 and 2006 comparing outcomes of CD patients undergoing either strictureplasty or bowel resection. Hazard ratios were calculated from Kaplan-Meier plots of cumulative recurrence data. Quality assessment of the included studies was performed. Random-effect meta-analytical techniques were employed. Sensitivity analysis and assessment of heterogeneity were performed.

RESULTS

Seven studies comprising 688 CD patients (strictureplasty n = 311, 45%; resection with or without strictureplasty n = 377, 55%) were included. Patients undergoing strictureplasty alone had a lower risk of developing postoperative complications than those who underwent resection (OR = 0.60, 95% CI: 0.31-1.16) although this was not statistically significant (P = 0.13). Surgical recurrence after strictureplasty was more likely than after resection (OR = 1.36, 95% CI: 0.96-1.93, P = 0.09). Patients who had a resection had a significantly longer recurrence-free survival than those undergoing strictureplasty alone (HR = 1.08, 95% CI: 1.02-1.15, P = 0.01).

CONCLUSION

Patients with small bowel CD undergoing strictureplasty alone may have fewer postoperative complications than those undergoing a concomitant bowel resection. However, surgical recurrence maybe higher following strictureplasty alone than with a concomitant small bowel resection. Patients may require appropriate preoperative counselling regarding the pros and cons of each operative technique.

Clinical significance of granuloma in Crohn's disease

Crohn's disease (CD) is diagnosed from information obtained clinically, pathologically, and radiologically. One important pathologic finding is a granuloma, which is helpful when a positive diagnosis of CD will affect treatment. Whether the presence of a granuloma has any clinical implication is not clear. We conducted a retrospective study to determine whether a granuloma found on a biopsy sample is associated with disease severity, fistulizing or perianal disease, frequent relapses, and extraintestinal manifestations. Eighty-two patients were identified who had a biopsy or bowel resection for CD between 1990 and 1994 at a tertiary referral center; 21 (25.6%) had a granuloma. This group was compared with a group of 61 patients without a granuloma. Forty-five percent were male (n = 37), mean age at diagnosis was 42.6 years (median, 39.5 years), mean disease duration at presentation was 8.8 years (median, 4.8 years), and mean follow-up duration was 2 years (range, 1 day to 10.2 years). No significant differences were demonstrated between the two groups by the Fisher exact test with regard to fistulizing or perianal disease, oral aphthous ulcers, disease severity, axial or peripheral arthralgia, episcleritis, anterior uveitis, erythema nodosum, or pyoderma gangrenosum.

Surgical pathology of Crohn's disease

This article discusses the gross endoscopic and histologic features of Crohn's disease. Terms used to describe the pathologic features are defined, and possible mechanisms and implications of development are discussed. The gross endoscopic and histologic correlation and the roles of the pathologist and endoscopist in making the diagnosis of Crohn's disease are emphasized.

Long-term results and multivariate analysis of prognostic factors in 138 consecutive patients operated on for Crohn's disease using "bowel-sparing" techniques

BACKGROUND

Conservative surgery has become accepted as a useful option for the surgical treatment of complicated Crohn's disease (CD).

METHODS

One hundred thirty-eight consecutive patients treated with strictureplasty or miniresections for complicated CD have been observed prospectively. The possible influence of a number of variables on the risk of recurrence was investigated using the Cox proportional hazard model, and a time-to-event analysis was made using the Kaplan-Meier function.

RESULTS

There was no perioperative mortality; the morbidity rate was 5.7%. A close correlation was found between the risk of recurrence and the time between diagnosis and first surgery. The overall 5-year recurrence rate was 24%, being 36% in the patients requiring surgery within 1 year of diagnosis and 14% in those operated on more than 1 year after diagnosis.

CONCLUSIONS

Risk factor analysis highlighted a group of patients at high risk of surgical recurrence. Given that our results are similar to those reported in other series, we consider strictureplasty and miniresections safe and effective procedures for the treatment of complicated CD.

The relationship between inflammatory and serosal connective tissue changes in ileal Crohn's disease: evidence for a possible causative link

The relationship between the gross connective tissue and inflammatory changes in ileal Crohn's disease remains unclear. This study investigated 20 patients undergoing ileal resection for Crohn's disease and 20 normal controls. The specimens were blocked in 1 cm serial sections and fully examined, including fresh morphometry and documentation of a range of pathological features. Pathological features of disease showed uniform distributions within affected segments, although specimens showed different patterns and severity of affliction. Serosal fat wrapping (FW) was present in all cases and was significantly greater than normals [mean 63.5% (SD 27. 8) vs. 21.0% (6.4), p<0.001], as was mesenteric thickening (MTh) [mean 18.0 mm (SD 11.1) vs. 5.9 mm (2.2), p<0.001]. The extent of FW correlated significantly with the degree of acute and chronic inflammation (r()=0.32 and 0.23 respectively, p<0.01), particularly the extent of transmural inflammation in the form of lymphoid aggregates (r()=0.35, p<0.01). MTh did not correlate with any features studied. These findings support the hypothesis that serosal connective tissue changes in Crohn's disease are related to the local effects of underlying chronic inflammatory infiltrates. Full thickness, radial samples from a grossly affected area are representative of the histopathological features present in a diseased segment as a whole.

Description of new "bowel-sparing" techniques for long strictures of Crohn's disease

In the period of January 1993 to December 1995 we operated on 55 patients with various complications of Crohn's disease. In properly selected cases, obstructive complications of Crohn's disease can be treated effectively by strictureplasty. Long strictures, even if a narrow lumen is still present, are commonly managed by resection, as classic strictureplasties cannot be done; also Finney strictureplasty seems inadequate, as it creates a blind loop that favors bacterial overgrowth and fecal stasis. Three original "sparing bowel" surgical approaches are proposed as possible alternative in the treatment of long stricture in Crohn's disease. We perform side-to-side ileoileal plasty whenever we are faced with severe narrowing of a long segment of small bowel (>10 cm); side-to-side ileocolic plasty whenever very severe disease with narrowing of ileocaecal valve is present; and ileocaecal plasty when terminal ileitis involves the very distal end of the small bowel, but sparing or only minimally affecting the ileocaecal valve. The above-mentioned procedures are described in detail and the clinical outcomes related to the first 8-patient series of our institution are presented.

Presence of granulomas is associated with recurrence after surgery for Crohn's disease: experience of a surgical unit

BACKGROUND

The determinants for recurrence of Crohn's disease remain controversial. Eight factors that might predict recurrence were studied in 130 patients operated on for Crohn's disease over a 24-year period.

METHODS

Separate survival curves were estimated for each variable. A multivariate analysis was then carried out in which several selected explanatory variables were included simultaneously in a proportional hazards regression model.

RESULTS

Operation for recurrent disease was necessary in 36 patients. Univariate analysis revealed a highly significant relationship between the presence of granulomas and subsequent recurrence (P = 0.003). There was a trend towards increased recurrence in patients with ileocolonic disease and segmental colectomy (P = 0.11 and P = 0.1 respectively). Age, sex, length of history, indication for operation and affected lines of transection were not associated with recurrence. After multivariate analysis, the association of granulomas with recurrence remained significant (P = 0.03). This association persisted when death was regarded as a treatment failure (P = 0.02).

CONCLUSION

The presence of granulomas in patients with Crohn's disease is significantly associated with recurrence.

Avoiding a stoma: role for segmental or abdominal colectomy in Crohn's colitis

Total proctocolectomy and ileostomy for Crohn's colitis offers a low recurrence rate but commits patients to a permanent ileostomy. In contrast, segmental resection may predispose patients to recurrence and further surgery but may delay or avoid a stoma in select individuals.

AIM

This study was undertaken to determine the risk of recurrence and the need for permanent stoma in patients treated with segmental or abdominal colectomy for Crohn's colitis.

METHODS

Between 1976 and 1985, 699 patients underwent surgery for Crohn's colitis at the Mayo Clinic. Patients who had a total proctocolectomy and end ileostomy or primary ileal or anorectal disease were excluded from further study. Fifty-three patients had a colon resection without a permanent stoma, and 49 were alive and available for follow-up. During a mean follow-up of 14 years, completed questionnaires provided current details on subsequent medical and surgical therapies and/or stomas that were required. In these 49 patients, Crohn's of the colon involved the right, left, and both sides of the colon in 12, 31, and 6 patients, respectively, and involved less than one-third, one to two-thirds, and greater than two-thirds of the colon in 23, 25, and 1 patients, respectively.

RESULTS

Twenty-two of forty-nine patients (45 percent) required no further therapy. In 27 patients (55 percent), further treatment was required, including 11 (22 percent) patients who were managed medically (only 4 >1 year) and 16 (33 percent) patients who were managed surgically. Three recurrences developed in the small bowel; the remaining 24 developed in the colon. For the 16 patients with recurrence requiring surgery, mean time to recurrence was 51 +/- 14 months; in all cases, recurrent disease involved the colon, with four anastomotic recurrences. At first recurrence, ten patients underwent another limited colon resection, and six patients underwent completion proctectomy with permanent ileostomy. Five patients required a third procedure, only one of which resulted in a permanent ileostomy. Therefore, 42 patients (86 percent) remained stoma-free, and 7 (14 percent) ultimately required permanent ileostomy, with a mean stoma-free interval of 23 +/- 4 months.

CONCLUSION

Colon resection without proctectomy in select patients with limited colonic Crohn's disease can delay or avoid the necessity of a permanent stoma.

Reoperative rates for Crohn's disease following strictureplasty. Long-term analysis

BACKGROUND

In Crohn's disease, ten-year reoperative recurrence rates after resection range from 30 to 53 percent. To determine the effect of strictureplasty on reoperative "recurrence" rates, experience at a single tertiary care institution was reviewed.

PATIENTS AND MATERIALS

Records of all patients who underwent strictureplasty for Crohn's disease from June 1984 to July 1994 at a tertiary care institution were reviewed. Data collected included duration of disease, medical and surgical history related to Crohn's disease, indications for strictureplasty, and longterm outcome.

RESULTS

One hundred sixty-two patients (87 male) underwent 191 operations for a total of 698 strictureplasties (Heineke-Mikulicz, 617; Finney's, 81). Mean number of strictureplasties was three, and mean patient age was 36 years. No mortality occurred. Cumulative five-year incidence of reoperative recurrence was 28 percent (95 percent confidence interval, 18.8-37.2 percent), with a median follow-up of 42 (range, 1-120) months. Obstructive symptoms were relieved in 98 percent of patients. To determine whether any difference in reoperative rates exists between patients who have strictureplasty alone and those who have strictureplasty with bowel resection, we divided patients in two groups, those receiving strictureplasty alone and those undergoing stricutreplasty plus resection. For patients treated by strictureplasty alone (Group A, n = 52; 32 percent), cumulative reoperative rate at five years was 31 +/- 9.6 (+/-standard error) and for patients with concomitant bowel resection (Group B, n = 110; 68 percent), it was 27.2 +/- 5.4 (+/-standard error). No statistical difference was present between these two groups. Of patients undergoing strictureplasty alone (Group A), operative recurrence was managed by new stricutreplasty in seven, by restricutreplasty in two, and by bowel resection in one. Among patients in Group B (strictureplasty and concomitant bowel resection), new strictureplasty was performed in 11, restrictureplasty in 6, and bowel resection in 9.

CONCLUSION

Strictureplasty is a safe and effective procedure for Crohn's disease in selected patients. Reoperative rates are comparable with resective surgery, and most recurrences occur at new sites.

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.

Factors influencing recurrence in Crohn's disease. An analysis of a consecutive series of 353 patients treated with primary surgery

PURPOSE

This study was undertaken to investigate the factors that influenced the risk of symptomatic recurrence in patients with Crohn's disease who were treated with primary resective surgery.

METHODS

Data regarding age, gender, time from diagnosis to surgery, medication, preoperative infectious complications, laboratory values, emergency/elective surgery, location and extent of disease, and resection margins were analyzed in relation to recurrence in 353 patients who were undergoing a "curative" resection in 1969 to 1986.

RESULTS

Univariate analyses showed a higher risk of recurrence in women with ileal and ileocolonic disease than in men (P < 0.05), in patients with ileocolonic disease compared with those with isolated ileal disease (P < 0.05), and in ileal disease patients with an increased disease extent (P < 0.05). In a multivariate analysis performed on patients with ileal disease, increased disease extent, limited resection on the colonic side, and referral from other hospitals were three independent variables that indicated an increased risk of recurrence (P < 0.05). Length of disease-free resection margins did not influence the risk of recurrence either in univariate or in multivariate analysis (P > 0.05).

CONCLUSIONS

Disease extent has prognostic value regarding the risk of symptomatic recurrence in Crohn's disease, whereas the length of resection margins does not influence the risk of relapse. These results favor a conservative approach, particularly in patients with extensive disease.

Surgical recurrence of perforating and nonperforating Crohn's disease. A study of 101 surgically treated Patients

PURPOSE

This is a study of the long-term course of surgically treated Crohn's disease designed to identify prognostic factors predictive of the time course and probability of surgical recurrence.

PATIENTS AND METHODS

The study is based on the records of 101 patients admitted to our institution for surgical treatment of Crohn's disease from January 1, 1970 to December 31, 1985. Follow-up was complete in 97 (96 percent) and incomplete in 4 patients. Median follow-up from the date of first operation was 13.25 years. The cumulative probability of requiring surgical treatment for recurrent disease was calculated using the life table method and further analyzed with the log-rank test and Cox regression.

RESULTS

The time to reoperation in this series was not significantly influenced by sex, age at onset of symptoms, age at diagnosis, age at first operation, anatomic location, and number of sites involved at the time of first operation. The only variable that had a statistically significant effect on the time to reoperation was characterization of disease at the time of operation as being perforating (P) opposed to nonperforating (NP). Median interval between the first and second intestinal operation was 1.7 years for the P group and 13 years for the NP group (P value, 0.005), and the median time between any two operations undergone during the study period was 2 years for the P group and 9.9 years for the NP group (P = 0.0002). The risk of having to undergo reoperation for recurrence was greatest during the first two years after an operation, and this was mainly because of a short time to surgical recurrence in the P group of indications. Therefore, the yearly hazard of requiring further surgery was maintained at approximately 5 percent.

CONCLUSION

The cumulative probability of requiring a reoperation for patients undergoing surgery for the P type of Crohn's disease is significantly different from that of patients with NP indications. The risk of having to undergo further surgery is particularly high during the first two years following an operation for perforating disease. The concept of a relatively aggressive perforating type of Crohn's disease and a more indolent nonperforating type is confirmed by the results of this study.

How safe is strictureplasty in the management of Crohn's disease?

BACKGROUND

Strictureplasty is a well-accepted technique in the management of selected patients with Crohn's disease. To determine the safety and optimal clinical setting for performing strictureplasty, perioperative complications and long-term outcomes need to be analyzed.

PATIENTS AND MATERIALS

We retrospectively reviewed the charts of 162 patients (87 men, 75 women) with Crohn's disease who underwent strictureplasty between June 1984 and July 1994. Medical and surgical history, including medications and laboratory data, intraoperative findings, perioperative complications, and long-term follow-up data were recorded.

RESULTS

These patients underwent 698 strictureplasties (Heineke-Mikulicz procedures, 617; Finney procedures, 81). Median hospital stay was 8 days. Perioperative septic complications were noted in 8 patients (5%); however, reoperation for sepsis was needed only in 5 patients. Five percent of patients developed prolonged ileus after strictureplasty. Symptomatic improvement after strictureplasty was achieved in 98% of patients. Restricture or new stricture or perforative disease was seen in 5% and 17% of patients, respectively, during a 42-month median follow-up period.

CONCLUSIONS

Our findings show that strictureplasty is a good surgical option for stenosing small-bowel Crohn's disease, particularly in patients with multiple obstruction and in those vulnerable to short-bowel syndrome. Perioperative complications are few, and long-term results are gratifying.

Recurrence and reoperation after strictureplasty for obstructive Crohn's disease: long-term results [corrected]

Strictureplasty extends the surgical options for the treatment of obstructive Crohn's disease. Over 15 years, 52 patients had 241 strictureplasties at 76 operations with no operative mortality and with septic complications in only two patients (4 percent). Median (range) follow-up was 49.5 (1-182) months. Nineteen patients (36 percent) required a second operation for Crohn's disease between 1 and 57 months after first strictureplasty. Most symptomatic recurrence was caused by new segments of stricturing or perforating disease, and recurrence of Crohn's disease was noted at only nine strictureplasty sites (3.7 percent) in four patients. Seven patients (13 percent) required a third operation for Crohn's disease. Patients undergoing strictureplasty alone were no more likely to require reoperation than those who had a concomitant resection at the first procedure (X2 = 0.619, P > 0.2). The reoperation rates after first and second operations were similar (X2 = 0.021, P > 0.2). Minimal surgery does not appear to lead to an accelerated or additional need for subsequent operation. Strictureplasty provides a safe, effective and rapid procedure to restore patients to good health while preserving the intestine and may be recommended for carefully selected strictures as an adjunct to conventional excisional surgical treatment.

Duration of recurrent ileitis after ileocolonic resection correlates with presurgical extent of Crohn's disease

Crohn's disease of the terminal ileum recurs in a predictable sequence proximal to the ileocolonic anastomosis after surgical resection. To confirm the suspicion that the duration of recurrent ileitis correlates with the extent of presurgical disease, this study investigated 23 consecutive patients with recurrent Crohn's disease symptoms who had undergone ileocaecal resections between 1982 and 1992 at our institution and had both preoperative and postoperative small bowel follow through studies available for comparison. All films were reviewed by a blinded gastrointestinal radiologist using uniform criteria. Symptomatic recurrence was reported at a mean (SEM) of 29 (25) months after resection. Presurgical length of inflammation averaged 26 (15) (8-57) cm and at recurrence 24 (14) (7-55) cm. The correlation coefficient (r) between pre and postsurgical extent of ileal disease was 0.70 (p < 0.0001). Seven patients had sequential small bowel series after 20 (10) (7-36) months without intervening surgery. The extent of measured inflammation between examinations correlated with r = 0.995 (p < 0.0001), showing the consistency of the measurement process. The close correlation between the duration of postoperative recurrence with the extent of presurgical disease is another example of individual patterns of recurrent Crohn's disease and is an additional factor to be considered when contemplating surgical resections.

Classification of the sequelae of bowel resection for Crohn's disease

A postoperative handicap index designed to predict diarrhoea and malnutrition following bowel resection in patients with Crohn's disease is proposed. The index takes into account the location and extent of resection, and its value can be calculated from operative records. Retrospective (n = 218) and prospective (n = 68) series of patients were studied. Diarrhoea and malnutrition developed in 102 patients (47 per cent) and 13 patients (6 per cent) respectively in the retrospective series, and in 40 (59 per cent) and one (1 per cent) of those in the prospective series. The handicap index correlated with faecal weight and faecal fat in 112 patients tested. Positive and negative predictive values of an index score greater than 20 for the development of diarrhoea, and over 50 for the development of malnutrition, were 0.64 and 0.90, and 0.60 and 0.99 respectively in the retrospective series; values were 0.80 and 0.71, and 0.25 and 1.00 in the prospective series. The postoperative handicap index is a useful tool for predicting the functional consequences of bowel resection for Crohn's disease.

Surgical therapy of chronic inflammatory bowel disease in childhood

The overall impression gained from the experience of the Departments of Paediatric Gastroenterology and Surgery attached to St Bartholomew's Hospital are the enormous benefits that surgery has to confer on the large percentage of children with both Crohn's disease and idiopathic proctocolitis who require it. The surgical procedures described in this chapter have been accompanied by a remarkably low complication rate, dispelling the impression that morbidity in such cases would be high. This must in large measure be due to the fact that the children who come to surgery are in as good a state of nutrition as can be achieved by means of the various forms of enteral and parenteral feeding now available. Anxiety about healing of anastomoses and the development of fistulas after surgery for example, has not been a feature of the surgical care of these patients. The principal benefit of surgery has been a clear demonstration of an improvement in growth velocity in both Crohn's disease and idiopathic proctocolitis patients provided always that surgery is correctly timed. It is the author's experience that maximum benefit is achieved if the bulk of the diseased bowel can be removed. Plainly relief of symptoms such as abdominal pain and diarrhoea has also been rewarding. In many instances second procedures such as restorative proctectomy in idiopathic proctocolitis can be timed to fit in with educational commitments. In Crohn's disease the likelihood of recurrence in adult life is high but these patients are in a fit state to cope with further therapy including surgery should the need arise. From the management point of view the close cooperation between physicians and surgeons at all stages has been crucial, firstly to achieve smooth preparation prior to surgery and satisfactory after care. But of even more importance in the assessment of Crohn's disease is the presence of all clinicians involved in the case in the operating theatre so that the surgical options are fully assessed. This united approach avoids any unnecessary anxiety when, as inevitably happens, recurrence of symptoms due to relapse occurs. The involvement of patients of whatever age, and parents in all the decision making processes from the time of diagnosis has been vital. Early discussion about stomas involving members of the Stomatherapy Department has been invaluable. One final important aspect of the management of these patients is the seamless hand-over of care to an adult combined medical and surgical clinic at an appropriate time, usually at the age of 17 years.(ABSTRACT TRUNCATED AT 400 WORDS)

Crohn's disease of the colon, rectum, and anus

The varied presentations and complexities of Crohn's disease involving the colon, rectum, and anus mandate decisions that can challenge even the most experienced surgeon. Symptomatic large-bowel disease, with its number of operative indications, is often amenable to resection that maintains intestinal continuity with acceptable rates of recurrence. Disease of the anus, occurring with or without proximal disease, typically is treated in a conservative manner, although occasional definitive treatment may yield improved results. As Crohn's disease is recognized as incurable, the treatment options discussed focus on the amelioration of symptoms while optimizing function without risking excessive morbidity.

Intraoperative enteroscopy in Crohn's disease

Intraoperative small bowel endoscopy was performed on 33 occasions in 31 patients with Crohn's disease. The extent of mucosal inflammation was compared with that of changes in the external bowel wall: serositis, fat-wrapping and mural thickening. The influence of endoscopic findings on surgical management was evaluated. Mucosal inflammation was generally more extensive than serositis (P < 0.01), but less so than mural thickening (P < 0.001). The extent of fat-wrapping did not differ from that of mucositis. Of 23 patients undergoing reoperation or with fistula or abscess, however, eight had serositis and/or fat-wrapping in bowel segments without mucosal inflammation. Endoscopic findings influenced surgical decisions on 20 of the 33 occasions, limiting planned resection in 14, identifying strictures for repair in one, and deciding against resection in two cases and for extended resection in three. These results suggest that external inflammatory changes are unreliable guides to the extent of intestinal mucositis and requirements for resection in Crohn's disease. By visualizing the mucosa, intraoperative enteroscopy can provide information for more precise surgery, thereby limiting resection.

Results of multiple strictureplasties in diffuse Crohn's disease of the small bowel

With extensive small bowel strictures due to Crohn's disease, resectional surgery may lead to short bowel syndrome. Strictureplasty (SP) has emerged as a useful alternative for selected strictures. This study reviews the results of 42 patients with diffuse obstructive Crohn's disease of the small bowel in whom at least four SP were performed in each patient (median: 7; range: 4-15; total SP: 315). Twenty-three patients (55%) had had 1-5 previous small bowel resections. Co-existing perforative disease was present in four patients (10%). Synchronous resection of a separate segment of small bowel was performed in 22 patients (52%). There was no operative mortality. Enterocutaneous fistula and/or intra-abdominal abscess developed in three patients (7%) and only one of these needed operative intervention. The median follow-up was 3 years (range: 10 months to 7 years). After SP, all patients experienced relief from obstructive symptoms. The median weight gain was 3 kg (range: -1-21 kg) and more than half the patients were weaned off steroids. Symptomatic recurrence occurred in 10 patients (24%) and was due to strictures (N = 9) and/or perforative disease (N = 2) at new site(s) unrelated to previous SP. Rate of symptomatic restricture of the SP site was 1.6% and was associated with new strictures elsewhere in all cases. Thus, in selected cases, SP is a safe and effective treatment for diffuse Crohn's strictures.