Crohn's ileitis and ileocolitis: a study of the anatomical distribution of recurrence

Outcomes and Endpoints of Postoperative Recurrence in Crohn's Disease: Systematic Review and Consensus Conference

BACKGROUND

Outcomes after ileocolonic resection in Crohn's disease [CD] are heterogeneous, and a clear definition of postoperative recurrence remains to be determined. Our Endpoints Working Group of the International Organization for the study of Inflammatory Bowel Disease [IOIBD] aimed to standardise postoperative outcomes, to discuss which endpoints should be used for postoperative clinical trials, and to define those which could be used in trials or registries.

METHODS

Based on a systematic review of the literature, recommendations and statements were drafted and sent to all IOIBD members for a first round of voting. Recommendations and statements were revised based on the voters' comments during a consensus hybrid conference open to all IOIBD members. If no agreement was reached after two rounds of voting, the statement was excluded.

RESULTS

In the systematic review, 3071 manuscripts were screened of which 434 were included. Sixteen recommendations were identified, of which 11 were endorsed. Recommendations and statements include that endoscopy remains the gold standard and should be used as a short-term primary endpoint in both observational cohorts and randomised controlled trials. Clinical symptoms classically used in clinical trials for luminal CD are not reliable in this specific situation. For that reason, longer-term endpoints should be based on the evidence of macroscopic inflammation assessed by imaging techniques, endoscopy, or as reflected by the presence of complications.

CONCLUSIONS

Agencies recommend the use of clinical evaluations, as in the case of luminal CD, and do not recognise primary endpoints based solely on endoscopy. This consensus has led to agreement on the need to define postoperative endoscopy-based and/or imaging-based endpoints.

Radiologic appearance of recurrent ileal Crohn disease

BACKGROUND

Postoperative recurrence of Crohn disease is a common problem. It has been assumed that the radiologic patterns are similar in de novo and recurrent ileal disease, but there has been little in the literature to actually confirm this belief.

METHODS

We retrospectively reviewed the small bowel examinations of 105 consecutive patients with a proven diagnosis of Crohn disease: a control group of 47 patients with no prior surgery and a postoperative group of 58 patients with resections. Of the latter, 22 had ileocecal or ileocolonic resections and 36 patients had ileocecal or ileocolonic and extensive enteric resections. We examined the disease sites and compared the disease patterns in both groups.

RESULTS

Fifty-six of 58 (97%) postoperative patients had anastomotic recurrences with proximal extension from 3 to 25 cm, with a mean of 10.5 cm; none showed distal disease extension. Two (3%) had enteric recurrences with neoterminal ileal sparing. There were no statistically significant differences in the length of distal/terminal ileal disease and the frequency of skip lesions in de novo and recurrent disease. There were lower frequencies of mucosal thickening, ulceration/ulceronodular mucosa, sacculation, loop separation, sinuses, and masses and a higher frequency of strictures in recurrent disease than in de novo disease. There was also a lower frequency of ulceration or ulceronodular mucosa after extensive resection than after limited resection.

CONCLUSION

Postoperative patients with ileal Crohn disease show a marked preponderance for anastomotic recurrence with proximal disease extension. There are significant differences in disease patterns in patients with de novo and recurrent disease.

Strictureplasty for ileocolic anastomotic strictures in Crohn's disease

PURPOSE

Because of the limited experience, the use of strictureplasty for a strictured ileocolic anastomosis associated with Crohn's disease was reviewed.

METHODS

We reviewed 22 patients who had a strictureplasty to treat symptomatic ileocolic anastomotic strictures related to Crohn's disease. The median interval between a previous ileocolic anastomosis and strictureplasty was 2 years (range, 1 to 26 years). The median age was 39 years and there were 15 males and 7 females. The median follow-up was 2 years.

RESULTS

Strictureplasty on a strictured ileocolic anastomosis was either a Heineke-Mikulicz (n = 15) or a Finney (n = 7) strictureplasty. Fifteen (68 percent) patients needed 47 additional strictureplasties in other sites of the small bowel and 5 (23 percent) patients had synchronous small bowel resection mainly for separate areas of phlegmonous disease. Only five (23 percent) patients did not have a synchronous procedure on the small bowel. There was no mortality or major septic complications. After surgery, relief of obstructive symptoms was noted in all patients. The median weight gain at six months after surgery was 3 kg (range, -5 to +10 kg) and 75 percent of the patients were weaned off steroids. Symptomatic "recurrence" occurred in two (9 percent) patients from new strictures at sites unrelated to previous strictureplasties; only one needed reoperation for recurrence. Patency of the strictureplasty on ileocolic anastomosis in asymptomatic patients was confirmed by small bowel contrast study (n = 12) and colonoscopy (n = 4).

CONCLUSIONS

Strictureplasty preserves small bowel length and may be a viable alternative to repeat ileocolic resection in suitable cases.

Crohn's disease and anastomotic recurrence: microvascular ischaemia and anastomotic healing in an animal model

Microvascular injury and ischaemia may be factors in anastomotic recurrence after resection for Crohn's disease. This hypothesis was explored in a ferret model of multifocal intestinal infarction. At laparotomy, isolated loops of small intestine were injected intraarterially with styrene microspheres (test loop) or saline (control). At a second laparotomy 72 h later, test and control loops were divided and an end-to-end anastomosis performed between test loops (n = 2), test and control loops (n = 9) or control loops (n = 2). Abnormalities including chronic transmural inflammation, ulceration and granuloma formation were identified 2 weeks after the second operation in ten of the 11 surviving animals; changes were confined to the test loops and were more prominent adjacent to the anastomosis. No abnormalities were seen in control loops. The combination of two self-limiting ischaemic insults can produce a pattern of intestinal inflammation similar to that seen in anastomotic recurrence in Crohn's disease.

The postoperative recurrence of Crohn's disease: an analysis of 37 patients with Crohn's disease who underwent endoscopy during initial surgery

A total 37 patients with Crohn's disease who underwent intraoperative endoscopy during resection of the affected intestine were evaluated in this study. The average age of the patients at surgery was 23.2 years. The residual lesions in the remaining intestine identified by intraoperative endoscopy were classified according to their pathologic profiles into three groups: A, B and C. In group A, comprising patients with longitudinal ulcers and/or a cobblestone appearance, 10 of 12 patients had recurrence. In 5 of these 10, the residual lesions were exacerbated and 2 required a further operation. The remaining 5 patients showed recurrence at the site of previous anastomosis and 2 of these 5 required additional surgery. In group B, comprising patients with small ulcers, aphthoid ulcers, or scars, and group C, comprising patients with no residual lesions, recurrence was observed in 13 of 16, and 3 of 9 patients, respectively. The recurrent lesions were all found proximal to, or at the site of previous anastomosis. Additional operations were performed on 3 of the group B patients. The findings of this study revealed that recurrence requiring additional surgery is more frequent at the site of anastomosis, regardless of the endoscopic appearance of the residual lesions.

Recurrence of Crohn's disease after resection

Recurrent Crohn's disease develops in most patients after surgical resection if the patient is followed for sufficient time. This review examines various aspects of recurrent Crohn's disease. It is concluded that Crohn's disease is a diffuse condition of the gastrointestinal tract and that radical resection of Crohn's disease does not prevent recurrence. Assorted factors thought to be associated with recurrence are examined and the relevance of these factors to the surgeon treating Crohn's disease is discussed.

The problem of postoperative recurrence of Crohn's disease

Most patients with Crohn's disease eventually require an operation and the overwhelming majority will ultimately experience a postoperative recurrence at the anastomotic site. Endoscopic lesions can be seen at the anastomosis in 85 per cent of patients by 3 years after surgery. While only 40 to 50 per cent of postoperative patients will ever undergo a second operation, clinical manifestations of recurrent disease develop at a cumulative rate of about 10 per cent per year. Postoperative recurrences of Crohn's disease are well recognized even after total proctocolectomy and ileostomy, but rates are higher following reanastomotic procedures. Evidence accumulated from published observations over the past 20 years, reinforced by new data from The Mount Sinai Hospital, suggests that Crohn's disease may follow at least two different patterns: "aggressive" disease characterized primarily by fistulae and abscesses, early requirement for surgery, and relatively rapid fistulizing-type recurrence; versus "indolent" disease characterized mostly by fibrotic stenosis and strictures, late requirement for surgery, and relatively slower obstructive-type recurrence. Pathophysiologic investigations and clinical trials alike should take into account this duality of clinical patterns. Regardless of the patterns of recurrence, however, surgery performed for proper indications is almost invariably rehabilitating for people disabled by the ravages and complications of Crohn's disease.

Natural history of recurrent Crohn's disease at the ileocolonic anastomosis after curative surgery

An endoscopical and histological study was carried out in 114 patients, treated by 'curative' resection of the terminal ileum and part of the colon for Crohn's disease, in order to study the natural history of recurrent Crohn's disease. The recurrence rate of Crohn's disease in patients examined within one year of the operation was 72%. This figure did not differ significantly from that in patients examined one to three years or three to 10 years after surgery (79% and 77% respectively). Recurrence was located in the neoterminal ileum and at the anastomosis in 88% of the patients. Early endoscopic signs of recurrence were small aphthous ulcers in the neoterminal ileum. Ileal biopsies at this stage showed an important inflammatory cell infiltrate of the lamina propria with numerous eosinophils and fusion and blunting of the villi. More advanced lesions observed in patients examined one to three years after surgery, consisted of larger, often serpiginous ulcerations and nodular thickening of folds. In patients examined three to 10 years after the operation, the anastomosis was frequently stenosed and rigid, with large ulcers extending from the stenosis into the colon. Mucosal granulomas may be found in normal appearing mucosa as well as in the obviously inflamed mucosa surrounding the ulcers. These studies suggest that recurrence of Crohn's disease almost always develops in the first year after the operation. Significant endoscopic lesions may be present without clinical symptoms, particularly in the earlier stages of the disease.

Postoperative recurrence in Crohn's disease. The effect of the initial length of bowel resection and operative procedure

We reviewed the surgical experience of 61 patients with Crohn's disease who have received surgical treatment over a 32-year period. Sex, age at onset of symptoms, associated systemic abnormalities, presenting symptoms, indication for previous surgery, and site of disease were not significant predictors of postoperative recurrence. Certain extensive resections of the small bowel are associated with a decreased probability of rehospitalization and reoperation. Resection of more than 25 cm of the small bowel and more than 50 cm of the "total" (small plus large) bowel was associated with a decreased likelihood of recurrence. Interestingly, analysis of larger resections (50, 75, 100 cm) failed to document a decreased likelihood of recurrence. The amount of large bowel resected did not predict postoperative recurrence. Bypass and diversion procedures offer a significantly enhanced risk for recurrent disease, whereas procedures employing resection are associated with lower probabilities of recurrent disease. We conclude that technically adequate resections of 25 to 50 cm of the small bowel or the combined small and large bowel are associated with a decreased probability of reoperation or rehospitalization after the initial surgery for Crohn's disease.

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%.