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

Pathophysiology and Treatment of Enteric Hyperoxaluria

Enteric hyperoxaluria is a distinct entity that can occur as a result of a diverse set of gastrointestinal disorders that promote fat malabsorption. This, in turn, leads to excess absorption of dietary oxalate and increased urinary oxalate excretion. Hyperoxaluria increases the risk of kidney stones and, in more severe cases, CKD and even kidney failure. The prevalence of enteric hyperoxaluria has increased over recent decades, largely because of the increased use of malabsorptive bariatric surgical procedures for medically complicated obesity. This systematic review of enteric hyperoxaluria was completed as part of a Kidney Health Initiative-sponsored project to describe enteric hyperoxaluria pathophysiology, causes, outcomes, and therapies. Current therapeutic options are limited to correcting the underlying gastrointestinal disorder, intensive dietary modifications, and use of calcium salts to bind oxalate in the gut. Evidence for the effect of these treatments on clinically significant outcomes, including kidney stone events or CKD, is currently lacking. Thus, further research is needed to better define the precise factors that influence risk of adverse outcomes, the long-term efficacy of available treatment strategies, and to develop new therapeutic approaches.

Different clinical outcomes in Crohn's disease patients with esophagogastroduodenal, jejunal, and proximal ileal disease involvement: is L4 truly a single phenotype?

BACKGROUND

The Montreal classification defines L4 Crohn's disease (CD) as any disease location proximal to the terminal ileum, which anatomically includes L4-esophagogastroduodenal (EGD), L4-jejunal, and L4-proximal ileal involvement. L4-jejunal disease was established to be associated with poor prognosis. However, the outcome of patients with L4-proximal ileal disease or L4-EGD remains to be clarified. Our study aimed to investigate whether the outcome differs among CD patients with L4-EGD, L4-jejunal, and L4-proximal ileal disease.

METHODS

In our retrospective cohort study, 483 patients with confirmed CD were included. The primary outcome was intestinal surgery. Demographic features and outcomes were compared among L4-EGD, L4-jejunal, and L4-proximal ileal disease.

RESULTS

Thirty-nine (8.1%) patients had isolated L4 disease, whereas 146 patients had L4 as well as concomitant L1, L2, or L3 disease. During a median follow up of 5.8 years, L4 patients were more likely to have intestinal surgeries compared to non-L4 patients (31% versus 16%, p < 0.001). The percentage of L4-jejunal patients who underwent surgery was higher than that of L4-proximal ileal (66% versus 28%, p < 0.001), and both of these subtypes of L4 were at higher risk for intestinal resection compared to L4-EGD patients (66% and 28% versus 9%, respectively, p < 0.001 and p < 0.05). On multi-variable analysis, L4-jejunal (HR 3.08; 95% CI 1.30-7.31) and L4-proximal ileal disease (HR 1.83; 95% CI 1.07-3.15) were independent predictors for intestinal resection.

CONCLUSIONS

L4 disease had worse prognosis compared to non-L4 disease. Within L4 disease, phenotype of L4-jejunal and L4-proximal ileal disease indicated higher risk for intestinal surgery. It might be justified to further characterize the L4 phenotype of the Montreal classification into three specific subgroups including L4-EGD, L4-jejunal, and L4-proximal ileal disease, similar to the Paris classification of pediatric patients.

Patients with perianal Crohn's disease have poor disease outcomes after primary bowel resection

BACKGROUND AND AIM

The presence of perianal disease in Crohn's disease patients is one of the factors of postoperative recurrence. The aim of this study is to evaluate long-term prognosis of perianal Crohn's disease patients in Asian.

METHODS

Patients with Crohn's disease who had undergone surgical bowel resection were divided into two groups according to the presence of perianal lesion. We monitored the occurrences of abdominal and/or perianal reoperation and readmission due to disease flare-up.

RESULTS

The 132 patients included in the study were divided into 2 groups, those with perianal disease (45 patients, 34.1%) and those without perianal disease (87 patients, 65.9%). Patients with perianal disease was younger in age (33.8 years versus 39.8 years, p = 0.015) and had been diagnosed as CD at a younger age (21.9 years versus 28.6 years, p = 0.005) than patients without perianal disease. Patients with perianal disease showed more extra-intestinal manifestation than patients without perianal disease (8 versus 3, p = 0.008). Reoperation was required in 46 (44.8%) patients during the follow-up period. The presence of perianal disease independently increased the risk of reoperation [hazard ratio (HR), 3.112; confidence interval (CI), 1.707-5.675]. Furthermore, patients with perianal disease had increasing risks of abdominal reoperation (HR 1.978; 95% CI, 1.034-3.784).

CONCLUSIONS

Patients with Crohn's disease and perianal lesions had a higher risk of reoperation. Considering these findings, physicians should consider aggressive and early top down therapy for patients with perianal Crohn's disease.

Prevention of post-operative recurrence of Crohn’s disease

Endoscopic and clinical recurrence of Crohn’s disease (CD) is a common occurrence after surgical resection. Smokers, those with perforating disease, and those with myenteric plexitis are all at higher risk of recurrence. A number of medical therapies have been shown to reduce this risk in clinical trials. Metronidazole, thiopurines and anti-tumour necrosis factors (TNFs) are all effective in reducing the risk of endoscopic or clinical recurrence of CD. Since these are preventative agents, the benefits of prophylaxis need to be weighed-against the risk of adverse events from, and costs of, therapy. Patients who are high risk for post-operative recurrence should be considered for early medical prophylaxis with an anti-TNF. Patients who have few to no risk factors are likely best served by a three-month course of antibiotics followed by tailored therapy based on endoscopy at one year. Clinical recurrence rates are variable, and methods to stratify patients into high and low risk populations combined with prophylaxis tailored to endoscopic recurrence would be an effective strategy in treating these patients.

Postoperative recurrent luminal Crohn's disease: a systematic review

Despite improved immunosuppressive therapy, surgical resection is still often required for uncontrolled inflammatory disease and the stenosing and perforating complications of Crohn's disease. However, surgery is not curative. A majority of patients develop disease recurrence at or above the anastomosis. Subclinical endoscopically identifiable recurrence precedes the development of clinical symptoms; identification and treatment of early mucosal recurrence may therefore prevent clinical recurrence. Therapy to achieve mucosal healing should now be the focus of postoperative therapy. A number of clinical risk factors for the development of earlier postoperative recurrence have been identified, and reasonable evidence is now available regarding the efficacy of drug therapies in preventing recurrence. This evidence now needs to be incorporated into prospective treatment strategies.

Review article: the natural history of postoperative Crohn's disease recurrence

BACKGROUND

Surgical resection of the diseased bowel in Crohn's disease is unfortunately not curative, and postoperative recurrence remains a problem in these patients.

AIM

To review the rates of and risk factors for clinical and endoscopic recurrence in population-based studies, referral centres and randomised controlled trials.

METHODS

We searched MEDLINE (source PUBMED, 1966 to September, 2011).

RESULTS

In randomised controlled trials, clinical recurrence in the first year after surgery occurred in 10-38% of patients, whereas endoscopic recurrence in the first year was reported in 35-85% of patients. In population-based studies, approximately half of patients experienced clinical recurrence at 10 years. In referral centres, 48-93% of the patients had endoscopic lesions (Rutgeerts' score ≥1) in the neoterminal ileum within 1 year after surgery, whereas 20-37% had symptoms suggestive of clinical recurrence. Three years after surgery, the endoscopic postoperative recurrence rate increased to 85-100%, and symptomatic recurrence occurred in 34-86% of patients. Smoking is the strongest risk factor for postoperative recurrence, increasing by twofold, the risk of clinical recurrence. Prior intestinal resection, penetrating behaviour, perianal disease and extensive bowel disease (>50 cm) are established risk factors for postoperative recurrence. Risk factors for postoperative recurrence remain poorly defined in population-based cohorts.

CONCLUSION

Endoscopic and clinical postoperative recurrence remains common in patients with Crohn's disease, and the identification of risk factors may allow targeted strategies to reduce this recurrence rate.

Preoperative risk evaluation of postoperative morbidity in IBD patients--impact of the POSSUM score

BACKGROUND

The aim of this study was to assess the morbidity and mortality of patients undergoing surgery for inflammatory bowel disease (IBD) with special focus of the predictive value of the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) scoring system for preoperative risk adjustment of postoperative morbidity.

METHODS

The operative notes and hospital files of 191 patients with IBD were analyzed. The POSSUM scoring system was used to predict morbidity rates after surgery. The physiological sub-score of the POSSUM score was analyzed with regard to its ability to predict postoperative complications.

RESULTS

The overall complication rate was 27.7%, and the mortality was 0.5%. The morbidity rate predicted by POSSUM was 28.4% and the mortality rate 7.2%. The mean POSSUM-phys sub-score in patients without the major complications (anastomotic leakages, peritonitis, bleeding) was significant lower compared to patients with at least one of these complications (14.7 vs. 18.6; p < 0.001). Regarding the major complications separately, there were significant differences in the POSSUM-phys scores in patients developing a sepsis (14.1 vs. 23.4; p < 0.001) and/or a peritonitis (14.8 vs. 19.2; p = 0.05), whereas patients developing an anastomotic leakage/suture dehiscence or a postoperative bleeding did not differ significantly.

CONCLUSION

POSSUM was an accurate predictor of morbidity in IBD patients and overpredicted mortality. The POSSUM-phys score is a promising instrument for identifying patients at increased risk of developing major postoperative complications after surgery for IBD.

Predicting, treating and preventing postoperative recurrence of Crohn's disease: the state of the field

The majority of patients diagnosed with Crohn's disease eventually require surgical intervention. Unfortunately, postsurgical remission tends to be short lived; a significant number of patients experience clinical relapse and many require additional operations. The pathogenesis of this postoperative recurrence is poorly understood and, currently, there are no reliable tools to predict when and in whom the disease will recur. Furthermore, the postoperative prophylaxis profiles of available Crohn's disease therapeutic agents such as 5-aminosalicylates, immunomodulators, steroids and probiotics have been disappointing. Recently, the combination of antibiotics and azathioprine in selected high-risk patients has demonstrated some potential for benefit. The goal of the present article is to provide a coherent summary of previous and new research to guide clinicians in managing the challenging and complex problem of postoperative Crohn's disease recurrence.

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.

Inflammatory bowel disease and African Americans: a systematic review

BACKGROUND

Inflammatory bowel disease (IBD) is comprised of Crohn's disease (CD) and ulcerative colitis (UC). There are conflicting reports on whether African Americans have a more severe disease course, presentation, and more frequent extraintestinal manifestations (EIM). We examined the precise nature of this relationship by conducting a systematic review.

METHODS

Using predefined inclusion criteria we searched multiple healthcare databases and Grey literature. Eight reports met the inclusion criteria. Using the parameters as defined in the Montreal classification and the presence or absence of EIM, we compared IBD in African Americans and Caucasians.

RESULTS

Over 2000 IBD cases were pooled from 8 reports with African Americans comprising 17%. African Americans and Caucasians had similar distribution of types of IBD, with CD being more common than UC in both groups (CD 76% versus 68% and UC 24% versus 32%, respectively). With respect to CD, both groups presented with nonstricturing and nonpenetrating disease behavior (55% versus 41%) more frequently and had similar rates of ileocolonic disease location (42% versus 38%), and presence of perianal disease (26% versus 29%). In UC patients, proctitis was the most frequent initial presentation in both races. Joint complications were the most frequent EIM in both African Americans (52%) and Caucasians (60%).

CONCLUSIONS

This study dispels the commonly held views that African Americans with IBD generally have more colonic disease, more severe disease behavior, and more perianal disease than Caucasians. African Americans also have similar variety and frequency of EIMs as compared to Caucasians.

[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.

Safety and efficacy of strictureplasty for Crohn's disease: a systematic review and meta-analysis

PURPOSE

This study was designed to review safety and efficacy of strictureplasty for Crohn's disease.

METHODS

A literature search was performed to identify studies published between 1975 and 2005 that reported the outcome of strictureplasty. Systematic review was performed on the following subjects separately: 1) overall experience of strictureplasty; 2) postoperative complications; 3) postoperative recurrence and site of recurrence; 4) factors affecting postoperative complications and recurrence; 5) short-bowel syndrome; and 6) cancer risk. Meta-analysis of recurrence rate after strictureplasty was performed by using random-effect model and meta-regressive techniques.

RESULTS

A total of 1,112 patients who underwent 3,259 strictureplasties (Heineke-Mikulicz, 81 percent; Finney, 10 percent; side-to-side isoperistaltic, 5 percent) were identified. The sites of strictureplasty were jejunum and/or ileum (94 percent), previous anastomosis (4 percent), duodenum (1 percent), and colon (1 percent). After jejunoileal strictureplasty, including ileocolonic strictureplasty, septic complications (leak/fistula/abscess) occurred in 4 percent of patients. Overall surgical recurrence was 23 percent (95 percent confidence interval, 17-30 percent). Using meta-regressive analysis, the five-year recurrence rate after strictureplasty was 28 percent. In 90 percent of patients, recurrence occurred at nonstrictureplasty sites, and the site-specific recurrence rate was 3 percent. Two patients developed adenocarcinoma at the site of previous jejunoileal strictureplasty. The experience of duodenal or colonic strictureplasty was limited.

CONCLUSIONS

Strictureplasty is a safe and effective procedure for jejunoileal Crohn's disease, including ileocolonic recurrence, and it has the advantage of protecting against further small bowel loss. However, the place for strictureplasty is less well defined in duodenal and colonic diseases.

Long-term clinical results of ileocecal resection for Crohn's disease

BACKGROUND

The efficacy of biologic agents in Crohn's disease (CD) has led to proposals that they be introduced early in the disease (top-down treatment) with the aim of reducing corticosteroid dependency and surgical resection. However, the long-term use of biologic agents in limited CD may be difficult to justify. The aims were to assess outcomes for ileocecal resection in CD and evaluate its role in the current era.

METHODS

The study included 139 CD patients who underwent ileocecal resection between 1980 and 2000. Data were retrieved from a prospectively maintained database. Disease recurrence was defined as symptoms in addition to endoscopic or radiological evidence of disease activity. Severe disease recurrence was defined as a need for repeat resection surgery.

RESULTS

Seventy-two (52%) patients developed disease recurrence. Median (interquartile range) time to recurrence was 7.1 (5-10.6) years. Forty-nine (35%) patients required repeat resection surgery. Median (IQ range) time to repeat surgery was 7.2 (4.9-10.8) years. The presence of granulomas was associated with disease recurrence (P = 0.03) and repeat resection surgery (P = 0.01).

CONCLUSIONS

Long-term outcomes for ileocecal resection in CD are excellent with 48% of patients remaining symptom-free and only 35% requiring repeat resection surgery at 10 years. This should be borne in mind when considering biologic therapy.

Operative management of small bowel Crohn's disease

Despite advances in medical treatment, most patients who have Crohn's disease of the small intestine need surgery at some point during the course of their disease. Surgery is currently indicated for intractable disease and complications of the disease (strictures, abscesses, fistulas, hemorrhage). There is increasing interest in nonsurgical and minimal access strategies of dealing with complicated disease, however. These new approaches may enable postponement of surgery to a more favorable time, or conversion of a two-stage procedure involving a stoma to a one-stage resection with anastomosis. A continuing challenge is prevention of disease recurrence postoperatively.

Long-term outcome after intestinal resection for Crohn's disease

OBJECTIVE

To assess the need for intestinal repeat resection for recurrence of Crohn's disease in patients observed for more than 20 years after the first resection.

MATERIAL AND METHODS

Data were gathered retrospectively from the medical records of 53 (28 F) consecutive patients with Crohn's disease from May 1954 to December 2002. Median age at first intestinal resection was 24.5 (range 13-65) years, and median observation time thereafter was 26.5 (20.1-48.6) years. Disease location and behaviour were defined according to the Vienna classification.

RESULTS

The 53 patients had an average 2.7 and a median 2 intestinal resections. Out of 144 intestinal resections (77.1%) 111 were performed during the first three operations; no alterations in distribution of ileal, ileocolic and colic resections were found. From the first to the third operation there was an increase in penetrating disease from 15% to 39% (p=0.046) concomitant with a decrease in stricturing disease from 72% to 44% (p=0.048) of the patients. There was also a corresponding decrease in ileocolic disease from 45% to 5% (p=0.003) and a tendency towards an increase in ileal disease from 38% to 67%. One patient died (1.8%) from rectosigmoid perforation after the third resectional operation. Six patients needed reoperation (11.3%) for ileus, anastomotic bleeding, rectosigmoidal perforation and abdominal pain. Thirty-four patients (64.2%) needed intestinal repeat resection (median 8.3 years) during 25.3 years after the first repeat resection.

CONCLUSIONS

This study indicates a diminution of Crohn's disease activity with time, as demonstrated by no need for intestinal repeat resection more than 25 years after the first resection.

European evidence based consensus on the diagnosis and management of Crohn's disease: special situations

This third section of the European Crohn's and Colitis Organisation (ECCO) Consensus on the management of Crohn's disease concerns postoperative recurrence, fistulating disease, paediatrics, pregnancy, psychosomatics, extraintestinal manifestations, and alternative therapy. The first section on definitions and diagnosis reports on the aims and methods of the consensus, as well as sections on diagnosis, pathology, and classification of Crohn's disease. The second section on current management addresses treatment of active disease, maintenance of medically induced remission, and surgery of Crohn's disease.

Factors affecting recurrence after surgery for Crohn’s disease

Although in Crohn’s disease post-operative recurrence is common, the determinants of disease recurrence remain speculative. The aim of this study was to examine factors affecting post-operative recurrence of Crohn’s disease. A Medline-based literature review was carried out. The following factors were investigated: age at onset of disease, sex, family history of Crohn’s disease, smoking, duration of Crohn’s disease before surgery, prophylactic medical treatment (corticosteroids, 5-amino salicylic acid [5-ASA] and immunosuppressants), anatomical site of involvement, indication for surgery (perforating or non-perforating disease), length of resected bowel, anast-omotic technique, presence of granuloma in the specimen, involvement of disease at the resection margin, blood transfusions and post-operative complications. Smoking significantly increases the risk of recurrence (risk is approximately twice as high), especially in women and heavy smokers. Quitting smoking reduces the post-operative recurrence rate. A number of studies have shown a higher risk when the duration of the disease before surgery was short. There were, however, different definitions of ‘short’ among the studies. Prophylactic cortic-osteroids therapy is not effective in reducing the post-operative recurrence. A number of randomized controlled trials offered evidence of the efficacy of 5-ASA (mesalazine) in reducing post-operative recurrence. Recently, the thera-peutic efficacy of immunosuppressive drugs (azathioprine and 6-mercaptopurine) in the prevention of post-operative recurrence has been investigated and several studies have reported that these drugs might help prevent the recurrence. Further clinical trials would be necessary to evaluate the prophylactic efficacy of immunosuppressants. Several studies showed a higher recurrence rate in patients with perforating disease than in those with non-perforating disease. However, evidence for differing recurrence rates in perforating and non-perforating diseases is inconclusive. A number of retrospective studies reported that a stapled functional end-to-end anastomosis was associated with a lower recurrence rate compared with other types of anastomosis. However, prospective randomized studies would be necessary to draw a definite conclusion. Many studies found no difference in the recurrence rates between patients with radical resection and non-radical resection. Therefore, minimal surgery including strictureplasty has been justified in the management of Crohn’s disease. In this review, the following factors do not seem to be predictive of post-operative recurrence: age at onset of disease, sex, family history of Crohn’s disease, anatomical site of disease, length of resected bowel, presence of granuloma in the specimen, blood transfusions and post-operative complications. The most significant factor affecting post-operative recurrence of Crohn’s disease is smoking. Smoking significantly increases the risk of recurrence. A short disease duration before surgery seems, albeit to a very minor degree, to be associated with a higher recurrence rate. 5-ASA has been shown with some degree of confidence to lead to a lower recurrence rate. The prophylactic efficacy of immunosuppressive drugs should be assessed in future. A wider anastomotic technique after resection may reduce the post-operative recurrence rate, though this should be investigated with prospective randomized controlled trials.

Clinical significance of granuloma in Crohn’s disease

AIM: Granuloma is considered the hallmark of microscopic diagnosis in Crohn’s disease (CD), but granulomas can be detected in only 21-60% of CD patients. The aim of this study was to evaluate the frequency of granulomas by multiple endoscopic biopsies in patients with CD and to examine whether group of patients with or without granuloma exhibit a different clinical course.

METHODS: Fifty-six patients with newly diagnosed CD were included in the study. Jejunoscopy, enteroclysis and ileo-colonoscopy were performed in all patients. At least two biopsy specimens from each examined gastrointestinal segment were examined microscopically searching granuloma. The clinical course was followed in all patients, and extraintestinal manifestations as well as details of any immunosuppressive therapy and surgical intervention were noted.

RESULTS: Granuloma was found in 44.6% of the cases (25 patients). Patients with granuloma had higher activity parameters at the time of the biopsies. Extraintestinal manifestations were observed and surgical interventions were performed more often in the granuloma group. The need of immunosuppressive therapy was significantly more frequent in the patients with granuloma. Granuloma formation is more often seen in younger patients, and mainly in the severe, active penetrating disease.

CONCLUSION: The significantly higher frequency of surgical interventions and immunosuppressive therapy suggests that granuloma formation is associated with a more severe disease course during the first years of CD.

Crohn's disease--when to operate?

Crohn's disease is a chronic bowel condition, which can present as a number of different clinical and pathological presentations, depending on localization and activity of the inflammatory process. The aethiology of the disease has not been explained. In each case the treatment should be individually tailored depending on the type of the changes. The indications for surgical intervention are continuous bleedings, recurrent ileus, perforation of the intestine, abscesses, fistulas, failure of pharmacological treatment, resistance to steroids and steroid dependence. In case of the mild type of the disease with few symptoms pharmacological treatment is the right choice In case of the mild type of the disease with few symptoms pharmacological treatment is the right choice process. In malign form of Crohn's disease lack of improvement after 7-10 days of intensive treatment is generally accepted indication for surgical treatment. Fulminant form of the disease is still a clear-cut indication for immediate surgical intervention. Decision on surgical intervention is more difficult and controversial when patient presents with series of subileus recurrences subsiding after conservative treatment. Patients with stenotic form of Crohn's disease usually require multiple operations most of which are bowel resections. Patients with stenotic form of Crohn's disease usually require multiple operations most of which are bowel resections therapy. External and internal asymptomatic fistulas should be treated conservatively. The timing of surgical treatment is essential in Crohn's disease however the prevention from recurrences is also fundamental. It is well proved that preventive administration of 5-ASA (especially mesalazine) and metronidazol can reduce the risk of early recurrences after surgery.

Frequency and significance of granulomas in a cohort of incident cases of Crohn's disease

BACKGROUND AND AIMS

Epithelioid granulomas is one of the best histological criterion for distinguishing Crohn's disease (CD) from other inflammatory bowel diseases. Few data are available on the time of occurrence of epithelioid granulomas, and the value of epithelioid granulomas in predicting outcome has been determined only in cohorts of prevalent CD cases. Our objective was to evaluate epithelioid granuloma occurrence in incident CD cases and to examine the associations between epithelioid granulomas and outcome.

PATIENTS AND METHODS

We reviewed the histological reports of endoscopic and surgical specimens in a cohort of 188 consecutive incident CD cases seen in 1994 and 1995, and recorded the occurrence of epithelioid granulomas, isolated giant cells, and microgranulomas. Kaplan-Meier curves were plotted for time from CD diagnosis to immunosuppressive treatment or surgery, and associations between epithelioid granulomas and outcome were evaluated in a multivariate analysis. Follow up was at least five years.

RESULTS

Granulomas were found in 69 (37%) patients, including 46 (25%) at presentation. Median time from CD diagnosis to epithelioid granuloma detection was 0.16 (0-63) months overall, and 9.59 (0.1-63) months in 23 patients who became epithelioid granuloma positive during follow up. Isolated giant cells were found in 6% of patients and microgranulomas in 12%. Epithelioid granuloma detection increased with the number of endoscopic sampling procedures; sampling site had no influence. By multivariate analysis, epithelioid granulomas were associated with surgical resection but not immunosuppressive therapy.

CONCLUSIONS

Epithelioid granulomas may separate CD into two pathological subsets and may indicate aggressive disease.

Crohn's disease over 20 years after diagnosis in a referral population

OBJECTIVES

Patients frequently ask questions about the lifetime prognosis of Crohn's disease. The aim of this study was to describe the outcomes of Crohn's disease more than 20 years after diagnosis.

METHODS

Data from all patients with Crohn's disease whose diagnosis had been performed before 1st January 1978 were analyzed. All referred patients filled in a medical and health-related quality-of-life questionnaire.

RESULTS

Among 273 patients with Crohn's disease diagnosed more than 20 years ago, 141 (52%) patients answered our questionnaire, 45 (16%) patients were alive but did not wish to answer our questionnaire, 51 (19%) could not be traced and 36 (13%) died before July 1998. At the end of follow-up, 25.7 (20.0-59.3) years after diagnosis, 24% had a relapse in the previous 12 months, and 48% and 28% had quiescent disease with and without treatment, respectively. These ratios were not different from those observed three years after Crohn's disease diagnosis. Sixteen patients died within 20 years after CD diagnosis, including 11 from CD-related causes. The risk of death estimated by Kaplan-Meier life-tables analysis was non-significantly higher if death was related to CD. An ileal or colic adenocarcinoma was noted in 6 (3.4%) patients.

CONCLUSIONS

Crohn's disease activity does not burn out with time, and roughly one-quarter of the patients had active disease 20 years after diagnosis.

Systematic review: has disease outcome in Crohn's disease changed during the last four decades?

BACKGROUND

Disease outcome in Crohn's disease might have changed during the last four decades. Disease outcome measurement in Crohn's disease has methodological difficulties because of patient selection and lack of proper definition of diagnostic and outcome measurement criteria.

AIM

To assess possible changes in disease outcome in Crohn's disease during the last four decades.

METHODS

A systematic literature search was performed using the MEDLINE search engine and major international conference libraries. Articles and abstracts were selected according to stringent inclusion criteria.

RESULTS

Forty articles and nine abstracts complied with the inclusion criteria. Seven studies with a median follow-up time between 11.1 and 17 years showed standard mortality ratios in Crohn's disease ranging between 2.16 and 0.72 with a tendency of decline during the last four decades. One study with 11.4 years mean follow-up time showed a statistically significant increased relative risk for colorectal cancer that was not confirmed by three others. Sixteen publications applied in the disease recurrence category. Probability of first resective surgery ranged between 38 and 96% during the first 15 years after diagnosis. The overall recurrence and surgical recurrence rates after first resective surgery ranged between 50 and 60, and 28 and 45% respectively during the following 15 years without an apparent time trend.

CONCLUSION

This structured literature review provides no hard evidence for change in disease outcome in Crohn's disease during the last four decades.

[Crohn's disease and pregnancy. About 34 cases. Review of the literature]

OBJECTIVE

To define the optimal conditions of pregnancy in patients affected by Crohn's disease.

MATERIAL AND METHOD

Retrospective study of 25 patients affected by Crohn's disease, followed during eight years at Rouen's University Hospital.

RESULTS

Twenty patients added up 34 pregnancies. Seventeen patients at least had a child, adding up 26 livebirths. Among the 17 pregnancies beginning with an active Crohn's disease, this proved to be still active in 16 cases. Among the eight interrupted pregnancies, six had an active disease. Out of the five menaces of preterm delivery stopped or not, four were in push. Eight neonatal hypotrophies were connected to a push.

DISCUSSION AND CONCLUSIONS

From a confrontation between the data of the literature and our experience, it emerges the following essential points: when Crohn's disease is quiescent, it does not affect the pregnancy, except a moderate fetal hypotrophy. When the disease is active, the risk of abortion and prematurity increases. There is no influence of the pregnancy on Crohn's disease, when pregnancy arises during a period of quiescence of the disease. Two thirds of the pregnancies of these women take place without new push of their disease. During pregnancy, there is no contraindication as far as the usual treatments of Crohn's disease are concerned, with a limitation however for the use of immunosuppressants.

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.

Azathioprine for prevention of postoperative recurrence in Crohn's disease: a retrospective study

BACKGROUND

The efficacy of azathioprine (AZA) in chronically active Crohn's disease (CD) is well established. Whether this drug is also useful to prevent recurrences after surgery is unknown. We report here our experience of AZA in this therapeutic goal.

METHODS

Between 1987 and 1996, 38 patients with CD were treated with AZA to prevent postoperative recurrence. Twenty-three of these had undergone a curative resection with removal of all previously involved parts of the gut. In the other 15 patients, resection was limited to the parts of the gut macroscopically abnormal at the time of surgery; those parts that were previously involved but normal at this time were conserved. The operative procedures were ileocolonic resection (n = 18), subtotal colectomy with ileorectal anastomosis (n = 12), coloproctectomy with ileo-anal anastomosis (n = 4) or ileostomy (n = 2), ileal resection (n = 1) and segmental colectomy (n = 1). Twelve patients had been treated previously with AZA before surgery; in 26 patients, AZA was started within the 2 months following surgery.

RESULTS

The median duration of postoperative follow-up was 29 months. Probabilities of clinical recurrence according to the Kaplan-Meier method were 9, 16 and 28% at 1, 2 and 3 years, respectively. For the 25 patients who had a colonoscopy or a small bowel barium X-ray during the follow-up, probabilities of anatomical recurrence were 16, 36 and 59% at 1, 2 and 3 years, respectively. The probability of anatomical recurrence was significantly higher in patients who had segments of the gut previously involved but not removed because they were macroscopically normal at the time of surgery.

CONCLUSION

In patients treated with AZA, the rate of postoperative endoscopic recurrence was lower than that previously reported in untreated patients. Our results suggest that AZA should be evaluated prospectively for prevention of postoperative CD recurrence, at least in high-risk patients.

Recurrence after colectomy in Crohn's colitis

PURPOSE

Previous studies on recurrence and reoperation after colectomy in Crohn's colitis have been based on heterogeneous groups of patients, and divergent findings may be explained by referral biases and small numbers of patients. The aim of this study was to account for recurrence rates, present risk factors for recurrence after primary colectomy, and account for the ultimate risk of having a stoma after colectomy with ileorectal anastomosis in patients with Crohn's colitis.

METHODS

Data on the primary resection, postoperative recurrence, influence of concomitant risk factors, frequency of stoma operations and proctectomy were evaluated retrospectively using multivariate analysis in a population-based cohort of 833 patients with Crohn's colitis.

RESULTS

The cumulative 10-year risk of a symptomatic recurrence was 58 percent (95 percent confidence interval, 53-63 percent) and 47 percent (95 percent confidence interval, 42-52 percent), respectively, after colectomy with ileorectal anastomosis and segmental colonic resection. In colectomy with ileostomy, lower rates were found with respectively 24 percent (95 percent confidence interval, 18-30 percent) and 37 percent (95 percent confidence interval, 32-43 percent) after subtotal colectomy and proctocolectomy with ileostomy. The multivariate analysis showed that perianal disease, ileorectal anastomosis, and segmental resection were independent risk factors for postoperative recurrence. In 76 percent of patients with ileorectal anastomosis, a stoma-free function could be retained during a median follow-up of 12.5 years.

CONCLUSION

Colectomy with ileorectal anastomosis or segmental resection is a feasible option in the surgical treatment of Crohn's colitis, although anastomoses, in addition to perianal disease, carry an increased risk of recurrent disease.

Safety and longterm efficacy of strictureplasty in 314 patients with obstructing small bowel Crohn's disease

BACKGROUND

Since its introduction in the early 1980s, strictureplasty (SXP) has become a viable option in the surgical management of obstructing small bowel Crohn's disease. Questions still remain regarding its safety and longterm durability in comparison to resection. Precise indications and contraindications to the procedure are also not well defined.

STUDY DESIGN

A retrospective review of all patients undergoing SXP for obstructing small bowel Crohn's disease at the Cleveland Clinic between 1984 and 1999 was conducted. A total of 314 patients underwent a laparotomy that included the index SXP The total number of SXPs performed was 1,124, with a median of two (range 1 to 19) per patient. Sixty-six percent of patients underwent a synchronous bowel resection. Recurrence was defined as the need for reoperation. Followup information was determined by personal interviews, phone interviews, or both.

RESULTS

The overall morbidity rate was 18%, with septic complications occurring in 5% of patients. Preoperative weight loss (p = 0.004) and older age (p = 0.008) were found to be significant predictors of morbidity. The surgical recurrence rate was 34%, with a median followup period of 7.5 years (range 1 to 16 years). Age was found to be a significant predictor of recurrence (p = 0.02), with younger patients having a shorter time to reoperation.

CONCLUSIONS

This large series of patients with longterm followup confirms the safety and efficacy of strictureplasty in patients with obstructing small bowel Crohn's disease. The 18% morbidity and 34% operative recurrence rates compare favorably with reported results of resective surgery. Caution should be used in patients with preoperative weight loss, because they experienced higher complication rates. Although young patients seem to follow an accelerated course, SXP remains indicated as part of an overall strategy to conserve intestinal length.

Risk factors for surgery and postoperative recurrence in Crohn's disease

OBJECTIVE

To assess the impact of possible risk factors on intestinal resection and postoperative recurrence in Crohn's disease (CD) and to evaluate the disease course.

SUMMARY BACKGROUND DATA

The results of previous studies on possible risk factors for surgery and recurrence in Crohn's disease have been inconsistent. Varying findings may be explained by referral biases and small numbers of patients in some studies.

METHODS

Data on initial intestinal resection and postoperative recurrence were evaluated retrospectively in a population-based cohort of 1,936 patients. The influence of concomitant risk factors was assessed using uni- and multivariate analyses.

RESULTS

The cumulative rate of intestinal resection was 44%, 61%, and 71% at 1, 5, and 10 years after diagnosis. Postoperative recurrences occurred in 33% and 44% at 5 and 10 years after resection. The relative risk of surgery was increased in patients with CD involving any part of the small bowel, in those having perianal fistulas, and in those who were 45 to 59 years of age at diagnosis. Female gender and perianal fistulas, as well as small bowel and continuous ileocolonic disease, increase the relative risk of recurrence.

CONCLUSIONS

Three of four patients with CD will undergo an intestinal resection; half of them will ultimately relapse. The extent of disease at diagnosis and the presence of perianal fistulas have an impact on the risk of surgery and the risk of postoperative recurrence. Women run a higher risk of postoperative recurrence than men. The frequency of surgery has decreased over time, but the postoperative relapse rate remains unchanged.

An audit of strictureplasty for small-bowel Crohn's disease

PURPOSE

The aim of this study was to review the long-term outcome of strictureplasty for small-bowel Crohn's disease.

METHODS

We reviewed 111 patients who underwent 285 primary strictureplasties (Heineke-Mikulicz, 236; Finney, 49) between 1980 and 1997.

RESULTS

Eighty-seven patients (78 percent) had had previous bowel resections. Forty-six patients (41 percent) required synchronous resection for perforating disease (abscess or fistula) or long strictures (>20 cm). The mean number of strictureplasties was three (range, 1-11). There were no operative deaths. Septic complications (fistula or intra-abdominal abscess) related to strictureplasty developed in eight patients (7 percent), of whom two required a proximal ileostomy. Abdominal symptoms were relieved in 95 percent of patients. The majority (95 percent) of patients with preoperative weight loss gained weight (median gain, +2 kg; range, -6 to +22.3 kg). After a median follow-up of 107 months, symptomatic recurrence occurred in 60 patients (54 percent). In 11 patients symptomatic recurrence was successfully managed by medical treatment. Forty-nine patients (44 percent) required reoperation for recurrence: strictureplasty alone in 22 patients, resection alone in 19 patients, strictureplasty and resection in 6 patients, and ileostomy alone in 2 patients. Eighteen patients (16 percent) required a third operation. One patient died from a small-bowel carcinoma which developed in the vicinity of a previous strictureplasty. Two of 19 patients with diffuse jejunoileal disease developed short-bowel syndrome, and were receiving longterm parenteral nutrition. Two other patients were taking corticosteroids for recurrent symptoms. All other patients were asymptomatic, receiving neither medical treatment nor nutritional support.

CONCLUSIONS

Strictureplasty is a safe and efficacious procedure for small-bowel Crohn's disease in the long-term.

Laparoscopic ileocecal resection for Crohn's disease associated with intestinal stenosis and ileorectal fistula

Although a complete remission of Crohn's disease can be induced by conservative therapy, surgical treatment is often required for patients with intestinal stenosis or fistulas, for whom minimally invasive laparoscopic surgery appears to be most appropriate. We herein report on a 26-year-old patient with Crohn's disease, who presented with an ileorectal fistula and severe stenosis of the terminal ileum and thus underwent laparoscopic surgery. The ileorectal fistula was divided intracorporeally using an autostapling device. The return to full activity after laparoscopic surgery is earlier than after open surgery, and the former approach is often beneficial for some patients with Crohn's disease. This is the first report of laparoscopic surgery for Crohn's disease associated with ileorectal fistula.

Follow up of more than 10 years after strictureplasty for jejunoileal Crohn's disease: long-term results and predictive factors for outcome

OBJECTIVE

The long-term outcome of strictureplasty for Crohn's disease is unknown. There have been few reports that have examined the predictive factors for outcome after strictureplasty. This study was undertaken to assess the long-term results and predictive factors for outcome following strictureplasty for jejunoileal Crohn's disease.

PATIENTS AND METHODS

Thirty-eight patients who underwent primary strictureplasty for jejunoileal Crohn's disease between 1980 and 1987 were reviewed.

RESULTS

Four patients developed an enterocutaneous fistula, of whom two had an intra-abdominal abscess. Two patients died during this study (one from leukaemia and another from small bowel carcinoma) and one patient was lost to follow up. All other patients have been followed for> 10 years. The 5- and 10-year cumulative reoperation rates for recurrence at the previous jejunoileal strictureplasty sites (site-specific recurrence) were 26% and 29%, respectively, after a median follow up of 13.5 years. After 5 years only one patient required surgery for site-specific recurrence. The only factor associated with a high rate of reoperation for site-specific recurrence was youth (<35 years). Gender, duration of symptoms, smoking habits, preoperative steroids therapy, preoperative albumin level, intra-abdominal abscess at laparotomy, number or length of strictureplasties, or previous or synchronous small bowel resection did not affect the reoperation rate.

CONCLUSIONS

Strictureplasty is a safe and efficacious procedure for jejunoileal Crohn's disease in the long term. Recurrence tends to develop early after strictureplasty, and late recurrence is uncommon. Only youth was a significant risk factor for site-specific recurrence requiring reoperation.

Inflammatory bowel disease

Although ulcerative colitis and Crohn's disease are relatively uncommon disorders, most primary care practices include a number of individuals with these diagnoses. Much of the initial evaluation and long-term care of these patients is managed or coordinated by their primary care physicians. A familiarity with current principles of diagnosis and treatment is essential. Ulcerative colitis and Crohn's disease are related, immunologically mediated disorders of unknown cause. Both are characterized by chronic relapsing courses, frequent need for surgical intervention, and increased colorectal cancer risk. Significant differences are seen between these two inflammatory bowel disease syndromes, in their histopathologic features, clinical manifestations, and response to treatment. This review focuses on the colorectal manifestations of inflammatory bowel disease, emphasizing clinical presentation, approach to diagnosis, medical and surgical management, and long-term prognosis.

Autologous bone marrow transplantation for non-Hodgkin's lymphoma resulting in long-term remission of coincidental Crohn's disease

Crohn's disease usually runs a chronic relapsing and remitting course, characterized by a repeated need for immunosuppressive drug therapy or often surgery. and is considered to be incurable by standard treatment. We report a case of successful long-term disease control of Crohn's disease following autologous bone marrow transplantation. This case provides further support for the concept that some forms of severe immune-mediated diseases may be amenable to treatment by high-dose therapy with autologous stem cell support.

Risk factors for early postoperative recurrence of Crohn's disease

BACKGROUND & AIMS

Despite many advances in our understanding of Crohn's disease, the course of the disease in any given patient remains unpredictable. There is little agreement as to which factors increase a patient's risk of early postoperative recurrence. We have attempted to identify predictors of early recurrence after surgical resection, specifically whether the indication for initial surgery (perforating or nonperforating) or the duration of preoperative disease may be associated with early recurrence.

METHODS

We studied 88 patients who had undergone at least two resections for Crohn's disease. Multivariable survival analysis was performed to elucidate predictors of early postoperative recurrence.

RESULTS

A perforating indication for initial surgery (P < 0.001) and a longer preoperative disease duration (P = 0.004) were found to be the only independent predictors of earlier postoperative recurrence after initial surgery. A longer preoperative disease duration also showed a borderline significant association with a shorter interval from second to third surgery (P = 0.075). Finally, the indication for initial surgery was predictive of the indication at a subsequent surgery for recurrence (P = 0.001).

CONCLUSIONS

A perforating indication for initial resection and a longer duration of disease before initial surgery predicted an earlier postoperative recurrence. The latter association was borderline. This suggests that prognostic groups based on these factors may help to stratify patients with regard to risk of early recurrence.

Controversies in Crohn's disease

Despite recent advances in the medical therapy of Crohn's disease, surgery continues to play a central role in the treatment of the disease. The strategy for surgical management of Crohn's disease continues to evolve. This chapter reviews many of the controversies surrounding surgical palliation of complications of Crohn's disease. Included is a discussion of indications for strictureplasty in treatment of intractable intestinal obstruction. Factors influencing long-term outcome with sphincter-saving resection in the treatment of Crohn's colitis are reviewed. Experience with definitive treatment of anal Crohn's disease and repair of rectovaginal fistulas is examined. Finally, recent experience supporting ileocolic resection when acute Crohn's ileitis is identified during laparotomy for right lower quadrant pain is critically evaluated. These controversial aspects of the surgical treatment of Crohn's disease reflect an improved understanding of the natural history of the disease as well as refinement in surgical techniques and better definition of criteria for surgical intervention.

Introduction of 6-mercaptopurine in Crohn's disease patients during the perioperative period: a preliminary evaluation of recurrence of disease

BACKGROUND

Recurrence of Crohn's disease after surgery is a common occurrence, pointing to the need for a strategy to prevent recurrent disease. We report the postoperative course of 10 patients who required intestinal resections for complications related to Crohn's disease.

METHODS

All patients had a Pediatric Crohn's Disease Activity Index score of 10 or greater. Among these patients, 5 began treatment with 6-mercaptopurine in the perioperative period. All 10 had received various combinations of prednisone and salicylate compounds. Patients who were given 6-mercaptopurine did not discontinue the medication until 2 years after the surgery.

RESULTS

To date, none of the five patients who were placed on 6-mercaptopurine have had recurrence of their Crohn's disease (mean disease-free period 32.6 +/- 18.4 months). Among those five patients not receiving 6-mercaptopurine there have been three relapses (mean time to relapse 3.7 +/- 1.2 months). Log-rank sum analyses of Kaplan-Meier survival curves show benefit to patients receiving 6-mercaptopurine in preventing relapses after intestinal resection (p < 0.05).

CONCLUSIONS

Although the underlying pathophysiologic reasons leading to the high relapse rate after intestinal surgery in Crohn's disease are unknown, we conclude that treatment with 6-mercaptopurine in the perioperative period may be warranted to help prevent the recurrence of Crohn's disease after surgery.

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.

Laparoscopically assisted ileocecal resection for Crohn's disease associated with intestinal stenosis and ileovesical fistula

We describe a 22-year-old man with Crohn's ileocolitis accompanied by intestinal stenosis and ileovesical fistula in whom laparoscopically-assisted surgery was successfully performed after thorough nutritional therapy. Laparoscopic procedures are characterized by minimal access and minimal invasion, features which can contribute to the early recovery of patients who undergo surgery. It is suggested that laparoscopic (or laparoscopically-assisted) surgery after strict nutritional therapy can be effective in the treatment of patients with Crohn's disease who have intestinal complications.

Crohn's disease in the Hunter Valley region of Australia

Between 1967 and 1991, 130 patients underwent surgery for Crohn's disease at The Royal Newcastle Hospital, New South Wales. There were more patients in recent years, which suggested an increased incidence of the condition (2.1/100 000/per year). The clinical profile and recurrence rate were similar to other studies. However, a greater proportion of patients required surgery for chronic small bowel obstruction and fulminant colitis compared with patients in other countries.

Maintenance of symptomatic remission in patients with Crohn's disease

Crohn's disease is a chronic inflammatory intestinal disorder characterized in most patients by repeated episodes of diminished and exacerbated symptoms. Recent controlled trials demonstrated that oral preparations of 5-aminosalicylic acid decrease recurrence rates by approximately 40% when administered long-term to patients with quiescent Crohn's disease. Orally administered corticosteroids, sulfasalazine, metronidazole, azathioprine, and cyclosporine have not proved of benefit in the prevention of recurrences of Crohn's disease. Nonetheless, corticosteroids, metronidazole, and azathioprine can control chronically active disease. Methotrexate may have some benefit in the treatment of active Crohn's disease, but its role in maintenance of remission has not been investigated. Elimination diets seem to prolong periods of symptomatic remission. Further studies are needed to define subgroups of patients who are most likely to benefit from preventive therapy.

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.

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.