Recurrences Following Surgery for Crohn’s Disease

Evolving roles of cross-sectional imaging in Crohn's disease

The implementation of cross-sectional imaging techniques for the clinical management of Crohn's disease patients has steadily grown over the recent years, thanks to a series of technological advances, including the evolution of contrast media for magnetic resonance, computed tomography and bowel ultrasound. This has resulted in a continuous improvement of diagnostic accuracy and capability to detect Crohn's disease-related complications. Additionally, a progressive widening of indications for cross-sectional imaging in Crohn's disease has been put forward, thus leading to hypothesize that in the near future imaging techniques can increasingly complement endoscopy in most clinical settings, including the grading of disease activity and the assessment of mucosal healing or Crohn's disease post-surgical recurrence.

Comparison of small bowel follow through and abdominal CT for detecting recurrent Crohn's disease in neoterminal ileum

PURPOSE

To assess the findings of recurrent Crohn's disease in the neoterminal ileum on small bowel follow through (SBFT) and computed tomography (CT) as well as the overall diagnostic performance of these imaging tests.

METHODS

Our radiology database yielded 52 patients with an ileocolic anastomosis for Crohn's disease who underwent SBFT and CT. The images were reviewed to determine the sensitivity, specificity, PPV, and NPV for individual findings of recurrent Crohn's disease in the neoterminal ileum. The overall sensitivity, specificity, PPV, and NPV of these tests for recurrent Crohn's disease were determined by comparing imaging reports to endoscopic and surgical findings in 45 patients (87%) and clinical response to treatment in seven (13%).

RESULTS

SBFT had a sensitivity of 90%, specificity of 85%, PPV of 95%, and NPV of 73% for detecting recurrent Crohn's disease, and CT had a sensitivity of 77%, specificity of 69%, PPV of 88%, and NPV of 50%. These tests combined had a sensitivity of 95%, specificity of 69%, PPV of 90%, and NPV of 82%. The most common findings were luminal narrowing, thickened folds, and ulcers (especially aphthoid lesions) on SBFT and bowel wall thickening on CT. CT also revealed extraenteric collections not visualized on SBFT in three patients (8%).

CONCLUSIONS

Our experience suggests that SBFT is more sensitive and specific than CT for detecting recurrent Crohn's disease in the neoterminal ileum, mainly because of the ability of barium studies to depict aphthoid lesions not visualized on CT. Conversely, CT is better for detecting extraenteric findings such as abscesses. When combined, these tests have a higher sensitivity for detecting recurrent Crohn's disease than either test alone.

Small bowel MR enterography: problem solving in Crohn's disease

Magnetic resonance enterography (MRE) is fast becoming the first-line radiological investigation to evaluate the small bowel in patients with Crohn's disease. It can demonstrate both mural and extramural complications. The lack of ionizing radiation, together with high-contrast resolution, multiplanar capability and cine-imaging make it an attractive imaging modality in such patients who need prolonged follow-up. A key question in the management of such patients is the assessment of disease activity. Clinical indices, endoscopic and histological findings have traditionally been used as surrogate markers but all have limitations. MRE can help address this question. The purpose of this pictorial review is to (1) detail the MRE protocol used at our institution; (2) describe the rationale for the MR sequences used and their limitations; (3) compare MRE with other small bowel imaging techniques; (4) discuss how MRE can help distinguish between inflammatory, stricturing and penetrating disease, and thus facilitate management of this difficult condition. Main Messages • MR enterography (MRE) is the preferred imaging investigation to assess Crohn's disease. T2-weighted, post-contrast and diffusion-weighted imaging (DWI) can be used. • MRE offers no radiation exposure, high-contrast resolution, multiplanar ability and cine imaging. • MRE can help define disease activity, a key question in the management of Crohn's disease. • MRE can help distinguish between inflammatory, stricturing and penetrating disease. • MRE can demonstrate both mural and extramural complications.

[Postoperative recurrence of Crohn's disease, and its prevention]

Crohn's disease is a chronic, progressive disabling condition ultimately leading to stricturing and/or penetrating complications. The need for surgery may be as high as 70% in patients with severe active disease or complications. However, relapse may develop in a significant proportion of the patients after surgery leading to frequent re-operations. Despite emerging data, postoperative prevention is still controversial. After careful evaluation of the individual risk a tailored therapy should be considered. In patients with small risk for relapse mesalazine or in selected cases no-treatment may be an option. In patients with a moderate-to-high risk azathioprine should be considered together with metronidazole in the three months. Follow-up ileocolonoscopy 6-12 months after the surgery is helpful in the determination of endoscopic severity and may assist in the optimization of the therapy. In most severe cases anti-TNF agents may be appropriate for postoperative prevention and therapy.

Endoscopy and MR enteroclysis: equivalent tools in predicting clinical recurrence in patients with Crohn's disease after ileocolic resection

BACKGROUND

Ileocolonoscopy poses the gold standard in the evaluation of postoperative recurrence of Crohn's disease (CD) at the site of ileocolonic anastomosis. Magnetic resonance enteroclysis (MRE) on the other hand is a promising technique for small bowel imaging. The aim was to compare MRE and ileocolonoscopy for predicting clinical recurrence in CD patients who have undergone ileocolonic resection.

METHODS

We included 29 patients in the study. The median time since index operation was 35 months and between ileocolonoscopy and MRE was 3 days. Patients were followed up for a maximum of 2 years unless clinical recurrence occurred earlier. Endoscopic findings were evaluated on a 5-grade scale (i0-i4), whereas MRE findings on the neoterminal ileum and anastomosis were assessed according to a previously validated 4-grade scale MR score (MR0-MR3).

RESULTS

By classifying patients into subgroups of endoscopic severity of postoperative recurrence using as a threshold an endoscopic score of i3, we found that 10% of patients in the i0 to i2 group had a clinical recurrence during the 2-year follow-up period as compared to 52.6% of subjects with i3 to i4 (P = 0.043). The corresponding clinical exacerbation rates in the subgroups based on MRE severity assessment were 12.5% for MR0 to MR1 and 50% for MR2 to MR3 (P = 0.09).

CONCLUSIONS

Our data suggest that colonoscopy and MR enteroclysis are of similar value to predict the risk of clinical recurrence in postoperative patients with Crohn's disease.

[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.

Review article: recurrence of Crohn's disease after surgery - the need for treatment of new lesions

Crohn's recurrence is the appearance of objective signs - defined radiologically, endoscopically or pathologically - of Crohn's disease in the bowel of a patient who has previously had a resection of all macroscopically diseased tissue. New lesions can be visualized endoscopically within weeks to months after ileal resection and ileocolonic anastomosis in the neoterminal ileum. The evolution of these lesions mimics the natural history of ileal Crohn's disease at the onset. If we are able to prevent recurrence of early lesions, we will probably interrupt the natural course of the disease. The drugs tested to date include different 5-aminosalicylate formulations, nitro-imidazole antibiotics, steroids and azathioprine. None of these therapies has convincingly been shown to prevent recurrent lesions. Metronidazole and ornidazole are effective, but cannot be used in the long-term because of side effects. Since there is a lag time of months to years between the development of recurrent lesions in the bowel and the recurrence of symptoms, we recommend performing imaging of the bowel 6 months after the operation to assess the severity of recurrence, and basing the further treatment strategy on this assessment.

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

BACKGROUND

Advances in the use of bowel-sparing surgery for Crohn's disease have led to the development of strictureplasty as an important technique to conserve small bowel length and reduce morbidity associated with malabsorption.

METHODS

A literature review of long-term studies on strictureplasty was undertaken, and evidence of its safety and efficacy was evaluated.

RESULTS

The safety and efficacy of strictureplasty is confirmed in retrospective studies carried out over a period of 5-10 years, particularly when employed in patients at risk of short bowel syndrome, but certain questions regarding bowel function and disease activity after surgery remain unanswered. There is also concern that diseased tissue is left in situ after strictureplasty; this tissue has the potential for malignant transformation in the long term.

CONCLUSION

Strictureplasty has been used in surgery for Crohn's disease for the past 25 years. Studies have proven its efficacy in the treatment of carefully selected patients at risk of malabsorption owing to short bowel syndrome.

Probiotics for the treatment of postoperative complications following intestinal surgery

Probiotics are living micro-organisms that belong to the normal enteric flora and exert a beneficial effect on health and well-being. The rationale for the therapeutic use of probiotics in pouchitis (the most frequent long-term complication following pouch surgery for ulcerative colitis) and postoperative recurrence in Crohn's disease is based on convincing evidence suggesting a crucial role for the endogenous intestinal microflora in the pathogenesis of these conditions. Positive results have been obtained with the administration of highly concentrated probiotic preparations in preventing the onset and relapses of pouchitis. Further controlled studies are needed to establish the efficacy of probiotics in the prophylaxis of postoperative recurrences of Crohn's disease and in the treatment of mild pouchitis.

Gender-related differences in the clinical course of Crohn's disease

OBJECTIVE

The aim of this study was to analyze the clinical and epidemiological differences between women and men affected by Crohn's disease.

METHODS

The clinical course of 275 female Crohn's disease patients was compared with that of 266 male patients.

RESULTS

Mean age at onset of symptoms and at diagnosis was 25.7 yr versus 27.7 yr and 28.8 yr versus 30.7 yr in women and men, respectively. Mean lag-time between onset of symptoms and establishment of the diagnosis were similar in both groups, without differences in presenting symptoms and initial localization of lesions. In women, however, some extraintestinal manifestations of Crohn's disease were found to occur more often. The percentage of patients who underwent an abdominal operation was quite similar in both groups (81% vs 77%). Mean lag-time between onset of symptoms and first bowel resection was not different. However, the lag-time between bowel resection and recurrence of disease was significantly shorter in women than in men (respectively, 4.8 yr vs 6.5 yr, p = 0.04), particularly regarding primary ileocecal resections. Overall, ileocecal resections were significantly more frequently performed in female than male patients (44% and 32%, respectively, p = 0.004). Female patients were also found to have significantly more often relatives in the first or second degree affected by Crohn's disease than male patients (15% vs 8.3%, p = 0.02).

CONCLUSIONS

Extraintestinal manifestations occur more often in female Crohn's disease patients than in male patients. Furthermore, an ileocecal resection, which is accompanied by an earlier recurrence, is more often performed in female than in male patients. Female patients have more often relatives with the same disease.

Postoperative recurrence of Crohn's disease: pathophysiology and prevention

Postoperative recurrence of Crohn's disease is often inevitable. Certain risk factors such as smoking, young age, and a perforating disease behavior have been identified. Patients running an enhanced risk should be treated with mesalamine or, with higher success rates, with azathioprine. An endoscopic evaluation of the neoterminal ileum 6 to 12 months after surgery provides relevant information predicting the further clinical course and can be used as a guide to adjust medical therapy.

Surgical therapy for Crohn's disease of the colon and rectum

Crohn's disease remains incurable by either medical or surgical treatment. Both physician and surgeon must work together with the common objective of restoring health by eliminating or alleviating the complications of Crohn's disease. From the surgeon's viewpoint, operation is performed for complications of the disease or for failure of medical management. Although aggressive surgical excision of affected bowel rids the patient of disease for a period of time, the beneficial effects of operation have to be considered in the context that disease recurrence is always a possibility and that reoperation for such complications may be necessary. The aim of the surgeon is to deal with the current problem as simply as possible and to maintain a long-term, strategic view of the disease process with the understanding that what is done today may affect the patient for life.

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.

Do microscopic abnormalities at resection margins correlate with increased anastomotic recurrence in Crohn's disease? Retrospective analysis of 100 cases

The relationship between histologic changes at resection margins and anastomotic recurrence was evaluated in patients with Crohn's disease. Pathology and medical records from 1960 to 1977 identified 100 patients who met the following criteria: 1) no prior surgery for Crohn's disease, 2) small bowel or small bowel and colonic resection with anastomosis done for Crohn's disease at the Cleveland Clinic, and 3) resection margins available for microscopic analysis. The following histologic features of the margins were evaluated: edema, inflammation, lymphoid aggregates, pyloric metaplasia, fibrosis, cryptitis and crypt abscesses, ulcers, granulomas, villous shortening, mucin depletion, neuronal hyperplasia, and transmural inflammation. Additionally, margins were categorized as histologically normal, showing nonspecific changes, showing changes suggestive of Crohn's disease, and showing changes diagnostic for Crohn's disease. Anastomotic recurrence occurred in 50 patients after an average follow-up period of 11.5 years. Cumulative recurrence-free rates for the four margin categories were not significantly different. Anastomotic recurrence was not associated with any clinical or histologic feature or combination of features.

Nutritional management of inflammatory bowel disease

The etiology and specific treatment of Crohn's disease and ulcerative colitis are unknown, and the treatment strategy for patients with inflammatory bowel disease is essentially symptomatic and supportive. The malnutrition that frequently accompanies inflammatory bowel disease is a manifestation of intestinal failure and should be vigorously corrected with total parenteral nutrition, elemental diets, or both. Evidence exists for the value of total parenteral nutrition and elemental diets as primary therapy for inflammatory bowel disease in selected patients. Judicious nutritional therapy remains a cornerstone in the adjunctive management of these patients.

Predictability of the postoperative course of Crohn's disease

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

Endoscopy in inflammatory bowel disease: indications and differential diagnosis

Colonoscopy with multiple biopsies adds a considerable amount of information to the overall clinical approach to the patient with inflammatory bowel disease. Because colonoscopy is an invasive procedure requiring a vigorous bowel clean-out, it is not a first-line investigative procedure for patients with inflammatory bowel disease. However, in certain indicated circumstances, colonoscopy can assist greatly in the management and diagnosis of patients with inflammatory bowel disease.

Clinical relapse of Crohn's disease under standardized conservative treatment and after excisional surgery

The course of 205 patients with Crohn's disease at one gastroenterological center was studied in patients with conservative drug treatment or with operative management of their disease. The decision for one or the other treatment regimen was made by an interdisciplinary team of gastroenterologists and surgeons. Using life-table analysis the 205 patients showed a clinical relapse rate of 27% after two years and 38% after four years. Clinical relapse was defined by a Crohn's disease activity index (CDAI) over 150. We used a standardized drug regimen of salazosulfapyridin and prednisone; the indication for excisional surgery was limited strictly to life-threatening situations, absolute nonresponse to drug treatment, and severe intervisceral fistulae. The operated patients (N = 93) had a lower relapse rate than the patients treated conservatively (N = 112), 20% and 51%, respectively, after four years. There were considerably fewer relapses in Crohn's colitis patients who were operated upon than in conservatively treated patients (18% versus 67% after four years); the same was found for ileocolitis (20% vs 49% after four years), but there was no difference between the treatment groups in ileitis (25-30% relapses for both after four years). In addition the patients with Crohn's disease of the colon had a more favorable course after resection with respect to symptoms, clinical and laboratory findings, and CDAI in remission. This paper gives data only for surgery in severe clinical situations and does not give a rationale for earlier surgery. This problem should now be studied in a randomized trial.

Segmental colonic resection is an appropriate operation for short skip lesions due to Crohn's disease in the colon

Thirty-six patients have had a segmental colonic resection for Crohn's colitis between 1948 and 1984. There were 2 deaths caused by intraabdominal abscesses present before operation. There were no cases of anastomotic dehiscence in the 29 patients having segmental resection and immediate anastomosis. The reoperation rate at 10 years was 66% (95% confidence interval, 48-84%), the majority of reresections being for recurrent large bowel Crohn's disease. The 10-year reoperation rates were higher than after subtotal colectomy and ileorectal anastomosis (53%; 95% confidence interval, 37-69%) performed in a comparable group of patients with colonic Crohn's disease. The difference did not achieve statistical significance. These findings suggest that when a patient with Crohn's disease has a short segment of diseased large bowel, a segmental resection is feasible and safe.

Multiple blood transfusions reduce the recurrence rate of Crohn's disease

In order to determine whether perioperative blood transfusion affects the recurrence of Crohn's disease, the authors reviewed the records of 79 patients with Crohn's disease who underwent their initial intestinal resection at their institution. Recurrence of Crohn's disease was documented by radiographic studies, endoscopy, or laparotomy. During the hospital admission for resection, 45 patients received multiple red blood cell transfusions. Recurrence developed in 22 percent of these patients by 36 months, and the median time to recurrence was 35 months. In the 34 patients who did not receive multiple transfusions, recurrence was found in 44 percent by 36 months, and the median time to recurrence was 20 months. These differences are significant, using the Kaplan-Meier analysis (P less than 0.04). Recurrence in patients with disease limited to the small bowel or to the colon was not significantly affected by the transfusion status. However, recurrence developed in only 10 percent of multiply transfused patients with ileocolic disease by 36 months, whereas recurrence developed in 45 percent of the patients who were not multiply transfused. (Significance, P = 0.057). The authors believe that the observed decreased rate of recurrence of Crohn's disease in patients receiving multiple perioperative transfusions may represent another example of clinically significant immunosuppression from blood transfusion.

Comparison of total parenteral nutrition and elemental diet in induction of remission of Crohn's disease. Long-term maintenance of remission by personalized food exclusion diets

Total parenteral nutrition or elemental diet can be used to induce remission of Crohn's disease. A randomized study has been conducted of 36 patients to assess the relative efficacy of the two techniques used without pharmacologic support; both were successful, and no significant differences emerged in the number of days to remission or the mean changes in Crohn's disease activity index, erythrocyte sedimentation rate, or serum albumin. The elemental diet is cheaper, simpler and safer. Uncontrolled clinical experience with 77 patients showed that personalized food exclusion diets were associated with an average annual relapse rate of only 11% for the first five years of diet alone; there have been six pregnancies and the longest remission is now 75 months. The use of elemental diet followed by the development of a personal food exclusion diet appears to be an effective long-term therapeutic strategy for Crohn's disease.

Factors affecting recurrence following resection for Crohn's disease

The records of 187 patients with Crohn's disease who underwent resectional surgery were analyzed to evaluate the effect of several clinical and histologic features on the recurrence rate. Recurrence was defined as the need for re-resection. The data were analyzed by the life-table method. Age, sex, age at onset of disease and at time of resection, family history, presence of granuloma, and microscopic involvement at the line of resection did not affect the recurrence rate. The distribution of the disease and duration of symptoms before primary resection did influence the rate of re-resection. Patients with predominantly large bowel disease (N = 56) were found to have a higher rate of re-resection (45 percent) when compared with 32 percent in patients with small bowel involvement (N = 94) and with 35 percent in patients with both small and large bowel involvement (N = 37) (P = 0.04). A detailed review, an analysis of the literature, and a comparison with our results are made.

Crohn's disease: maintenance of remission by diet

20 patients with Crohn's disease took part in a controlled trial in which remission was maintained by either an unrefined carbohydrate fibre rich diet or a diet which excluded specific foods to which a patient was intolerant. 7 out of the 10 patients on the exclusion diet remained in remission for 6 months compared with none out of the 10 on an unrefined carbohydrate fibre rich diet (p less than 0.05, Fisher's exact test). In an uncontrolled study an exclusion diet allowed 51 out of 77 patients to remain well on the diet alone for periods of up to 51 months, and with an average annual relapse rate of less than 10%.

Recurrence after surgery in Crohn's disease. Relationship to location of disease (clinical pattern) and surgical indication

Among 615 patients with Crohn's disease originally diagnosed at the Cleveland Clinic Foundation from 1966 to 1969, 592 have been followed (96%) for a mean of 13 yr. Of these, 438 had undergone operation. The purpose of this study was to determine how many of these patients had developed recurrences requiring another operation and to relate recurrences to the original anatomic location of disease (the clinical pattern) and surgical indication. Those patients with ileocolic disease had the highest recurrence: 53% compared with 45% for colonic and 44% for small intestinal patterns. Second recurrences were ileocolic pattern 35%, colon 34%, small intestine 38%. The estimated median time of recurrence was similar among these three groups. The presence of internal fistula or perianal disease as an indicator for surgery were associated with a higher likelihood of recurrence and a shortened estimated median time to recurrence. This study supports the concept of conservatism with regard to the management of these two complications for patients with Crohn's disease.

Crohn's disease. A long-term study of the clinical course in 186 patients

A series of 186 patients treated for Crohn's disease during the period 1956 to 1968 has been followed up in 1970, 1975, and now in 1983. Among 173 patients operated on there were 89 recurrences (52%). After a follow-up time greater than 14 years (mean, 18 years) 'radical' resections at the first operation gave a lower recurrence rate (31%), fewer reoperations, and a better quality of life compared with non-'radical' resections (recurrence rate, 83%). The quality of life estimated for all patients alive in 1983, 152 patients, was good in 89%; 8.6% had moderate subjective symptoms, and 2.6% had pronounced subjective symptoms. With an increasing follow-up time there was no decrease in the patients' quality of life. Ileorectal anastomosis did not give very good results; proctocolectomy and ileostomy, however, gave good results. Regular investigation of all patients is of vital importance to give them a good quality of life.

Survey of the use of colonoscopy in inflammatory bowel disease

In a survey of patients with inflammatory bowel disease (IBD), colonoscopy with multiple biopsies has been shown to be superior to either colonoscopy alone or barium studies in assessing disease extent. Thus, of a total of 149 patients, 23 (15%) were considered to have total colitis on barium enema, 51 (34%) on macroscopic colonoscopy appearance compared to 92 (62%) on biopsy. Furthermore, radiological assessment of "skip lesions" was shown to be unreliable. Although it remains to be seen whether the more accurate delineation of disease extent achieved by endoscopy is advantageous in terms of clinical management, it may have implications for our understanding of the 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.

Detection of surgical lesions of the small bowel by enteroclysis

Enteroclysis is an examination in which barium is infused directly into the small intestine, and compression radiographs are taken on each segment. This method eliminates many of the inherent limitations of the conventional small bowel follow-through examination. This report concerns 45 patients with 48 small bowel lesions. They were missed on the conventional examination but detected within 3 months by subsequent enteroclysis and confirmed surgically. There were 15 patients with Meckel's diverticula, 7 with obstructive adhesive bands, 5 with Crohn's disease, 5 with blind pouch syndrome (1 with a leiomyoma inside the blind pouch), 2 with other leiomyomas, 3 with metastatic carcinoma, two with primary carcinoma 3 with radiation stricture, two with sinus tract lesions and fistulas, and 1 with another lesion. Improved intubation techniques and better barium mixtures make enteroclysis possible in most hospitals. As surgeons appreciate the value of enteroclysis, they can request this examination for appropriate patients to sooner find many surgical lesions of the small bowel which frequently go undiagnosed.

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.

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.

Split ileostomy and ileocolostomy for Crohn's disease of the colon and ulcerative colitis: a 20 year survey

The clinical course of 140 patients who have had a split ileostomy for ulcerative colitis or colonic Crohn's disease over a 20 year period is reported. In 37 patients with ulcerative colitis there was no sustained improvement. In the 102 patients with Crohn's disease there was an immediate clinical improvement in 95, which was sustained in 65. Thirty patients have subsequently required a proctocolectomy for persistent inflammation, and 28 are still defunctioned. Bowel continuity was restored after 61 split ileostomies and in 44 patients intestinal continuity remains intact at the present time (mean follow up since closure = 62.5 months, range 0-231 months). It is concluded that a split ileostomy is a safe conservative operation producing at least temporary improvement in severely ill and malnourished patients with Crohn's colitis, and that if a subsequent resection becomes necessary it may be less extensive than was thought applicable at the initial operation. In 27 patients a resection has not been required.