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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Surgical therapy of recurrent Crohn's disease

and .

Department of Surgery, University Hospital Benjamin Franklin, Freie Universität Berlin

As yet, there is no cure for Crohn's disease. Neither medical nor surgical therapy can avoid its recurrence. Crohn's disease has primarily to be treated conservatively. Surgery is only necessary when complications occur. Nevertheless 80% to 90% of all Crohn patients have to undergo surgery at least once (1). One year after ileocecal resection Rutgeerts et al. (2) found an endoscopical recurrence in 73%; 20% of which had clinical symptoms. After three years recurrence rates increased to 85%, with clinical symptoms in 34%. According to these two studies there is macroscopical evidence for recurrent Crohn's disease very early after operation. The cumulative recurrence rate, defined as the number of patients who have to be reoperated, however, is considerably lower (33–58% after ten years) (table I).

Table I. Cumulative recurrence rates (modified according to Williams et al. (33)).

Table I

Cumulative recurrence rates (modified according to Williams et al. (33)).

Definition of recurrence

As mentioned above there are different forms of recurrence in Crohn's disease which can be defined as follows:

1.

Endoscopical recurrence: Specific macroscopical alterations as defined by Rutgeerts (3) found during planned postoperative endoscopy. Additional histological examination facultative.

2.

Radiological recurrence: Stenosis or irregularities of the intestinal mucosal surface seen on images (by the use of contrast media or other techniques) of the small intestine.

3.

Clinical recurrence: Symptoms specific for Crohn's disease as judged e.g. by the Crohn's Disease Activity Index (CDAI).

4.

Reoperation: Indication for operation due to one of the first three types of recurrence with histological confirmation of the diagnosis.

These four definitions have different values. The most severe criterion for a recurrence is the indication to reoperate. However, the indication for surgery is based on clinical symptoms, endoscopy and radiology as well as on the subjective decision of the gastroenterologist and surgeon. But even this is not always comparable between different institutions.

Clinical symptoms, which are the most visible signs of recurrence for the patient, are difficult to quantify. The commonly used Crohn's Disease Activity Index (CDAI) has a low sensitivity for scary stenosis and the bowel movements of patients with enterostomies cannot be assessed.

Endoscopy and radiology have a high sensitivity for morphological changes but are of limited value for the diagnosis of clinically relevant recurrence.

Factors influencing recurrence

Several factors have been suggested to influence recurrence. This discussion, however is most controversial.

Age at onset of the disease

Greenstein et al. found a recurrence rate of up to 50% within a five-years follow-up in patients younger than 25 years at the onset of the disease. For the long-term, however, most authors report comparable recurrence rates (4). Some studies did not even find an increased recurrence rate (3, 5, 6).

Sex

Some studies could not find sex-related differences although an influence of smoking in female patients is discussed (2, 7).

Duration of Crohn's disease before resection

Some authors have suggested that recurrence is more frequent in patients with a history of Crohn's disease of two years or less before resection (8, 9, 10). Sachar et al. (11) reported a significantly higher recurrence rate in patients who had Crohn's disease for less than ten years compared with patients with a longer duration. However, cumulative recurrence rates of patients with a short history of Crohn's disease compared to a long history were different in other studies (12, 13).

How can these different findings be explained? Firstly, the duration of Crohn's disease before resection is generally easy to measure. However, symptoms are usually present for a variable period of time before diagnosis. This interval is often hard to appraise. Secondly, the length of the preoperative history is a continuous variable and most studies have divided the group of patients into two roughly equal halves, based on an arbitrary period which varies from study to study.

Smoking

Some authors could show a fivefold increase of recurrence rates for smokers compared to non-smokers (14, 15, 16). Likewise Sutherland et al. found increased postoperative recurrence rates for smokers (17). Hence every operated patient should be informed about an increased risk of recurrence in case of smoking.

Site of bowel involvement

Farmer et al. (18) identified different patterns of Crohn's disease, based on three main sites of intestinal involvement:

1.

Ileocolic with involvement of the distal ileum and right colon;

2.

small intestine, with disease confined to the small bowel and

3.

colonic, with disease confined to the colon.

These three clinical types of involvement were associated with significant differences with regard to symptoms, complications and the necessity of surgery. The highest recurrence rate was found in ileocolic (44%), 33% in small bowel Crohn's disease and 18% for the colon. Patients after segmental colonic resections had higher recurrence rates than after proctocolectomy (19, 20). The risk of recurrence after a second resection was different in studies with small numbers of patients (4, 6), but not significantly different in larger series.

Type of disease

In one of the most discussed studies of the last decade Greenstein et al. worked out two types of Crohn's disease differentiating perforating from a non-perforating type (21). Greenstein postulated a higher recurrence rate for patients with perforating Crohn's disease, but these results were not confirmed by many other studies (22, 23, 24). Hence a prediction of recurrence based on this differentiation is not possible.

Involvement of disease at the resection margins

The influence of disease at the resection margin on recurrence has been one of the more contentious areas in the surgery of Crohn's disease. Lower recurrence rates have been claimed for radical resection with macroscopically normal resection margins, compared to non-radical resection with involved margins (25). Especially Lindhagen, Fazio, Kotanagi and Wolff demonstrated that microscopical involvement of the resection margin has no influence on the recurrence rate (26, 27, 28, 29). At least it is generally accepted that a diseasefree margin of 1–2 cm is sufficient.

As far as the colon is concerned a higher recurrence rate has been demonstrated after ileorectal anastomosis to macroscopically normal rectum (30, 31, 32). Although proctocolectomy has lower recurrence rates, permanent stoma should be avoided as long as possible. At present the value of minimal surgery in segmentally diseased colon is questionable.

Surgical principals in recurrent Crohn's disease

Basically surgery in recurrent Crohn's disease follows the same principles than in primary surgery.

Preparation

Preoperatively a complete Crohn-staging should be performed including endoscopy, radiological imaging of the small intestine and in case of anorectal Crohn's disease anal manometry and endosonography.

An improved nutritional status should be provided by preoperative parenteral nutrition in case of malnutrition.

Prior to the operation the surgeon has to study the protocol of the previous operation(s). Special emphasis should be taken to the length of the resection, the nature of the anastomosis and the total length of the remaining intestine.

Surgery

The high recurrence rates of Crohn's disease especially after reoperations require a minimal surgery. During every step of the operation the next possible recurrence should be kept in mind.

Prior to resection the total length of the gut must be measured and noted in the operation report.

Ewe et al. demonstrated an increased risk of recurrence after radical resection with lymphadenectomy. The median recurrence-free interval after radical resection compared to non-radical resection was 15 vs. 36 months (33). This and the results of many other studies which demonstrated only the need of a 1–2 cm macroscopically disease-free resection margin leaded to a specific surgical strategy.

In contrast to carcinoma surgery there is no indication for radical resection or for lymphadenectomy. Only the diseased gut has to be resected. The preparation of the vessels should be performed close to the gut. In our experience end-to-end anastomosis should be performed to prevent blind-loops. Also we prefer resorbable sutures to prevent fistula formation. However, there is no prospective data confirming this.

Conservative Crohn surgery involves also the application of the strictureplasty techniques (figure 1) for short stenoses. The advantage of this method is the preservation of the continuity without a loss of intestine. Many authors demonstrated the great clinical implication of this surgical technique, including a low recurrence rate of 10–18% after a median of three years (34, 35).

Figure 1. Schematic drawing of the operative principle of strictureplasty.

Figure 1

Schematic drawing of the operative principle of strictureplasty.

A special problem in Crohn surgery is the presence of a diseased segment within a conglomerate-tumor. In this case the whole intestinal conglomerate has to be adhesiolysed to identify the diseased segment.

Transabdominal drains should be avoided in Crohn surgery due to the high risk of enterocutaneous fistula formation.

The basical principles Crohn's disease surgery have been worked out in the previous chapter. Nevertheless there are some special features for recurring disease.

1.

Enterocutaneous fistulas: In unoperated patients enterocutaneous fistulas arise from blindly ending fistulas to the abdominal wall, whereas in recurrent Crohn's disease they arise more likely from former anastomoses in the sense of a late leakage. Surgery is indicated in the case of abdominal wall abscesses, skin damage due to a highly active secretion and in a functional short bowel syndrome. The operative therapy consists of limited resection of the diseased segment with primary end-to-end anastomosis.

2.

Blindly ending fistulas in recurrent Crohn's disease: As in enterocutaneous fistulas these fistulas usually originate from former anastomoses in the sense of a late leakage. They go to the retroperitoneal tissue and form there abscesses. This situation has to be considered as an absolute emergency. For surgery the diseased segment again must be resected and the fistula tract and abscess consequently debrided.

3.

Anorectal Crohn's disease: As almost no other Crohn manifestation anorectal Crohn's disease has a very high recurrence rate. Here each recurrence can lead to a progressive destruction of the anal sphincter and the necessity of proctectomy with a permanent stoma. According to Wolff et al. (36) the cumulative risk of proctectomy in anorectal Crohn's disease is 8,4% after ten years and 17,5% after 20 years. The indications for proctectomy in anorectal Crohn's disease are (1) severe perianal fistula tracts with destruction of the anal sphincter, (2) lacerations of the anal sphincter due to former fistula operations, (3) fistula-associated carcinomas, and (4) intractable proctitis.

In the case of surgery proctectomy is performed under preservation of the pelvic floor and, as far as possible, the anal sphincter (figure 2).

Figure 2. Closure of the muscular pelvic floor in Crohn's disease.

Figure 2

Closure of the muscular pelvic floor in Crohn's disease.

Conclusion

Most patients will develop overt recurrence after resection of Crohn's disease if they are followed for a long time. Subclinical changes suggestive of recurrence may develop soon after surgery. Radical resection does not appear to sufficiently protect against recurrence, therefore conservative resections should be performed to preserve intestinal length. What predisposes certain intestinal sites to the development of recurrent disease remains unexplained. Finding the answer to this conundrum will probably result in a better understanding of recurrence and may result in specific treatment aimed at its prevention.

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Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6915

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