Recurrence in Crohn's disease - Hindawi Publishing Corporationmethods are used to correct for varrn tions m follnw-up inrerval. Most authors find no difference in recurrence rates

RECURRENCE AND ITS PREVENTION

Recurrence in Crohn's disease

ADRIAN J GREENSTEIN, MD, FACS, FRCS

AJ GREENSTEIN. Recurrence in Crohn's disease. Can J Gastroenterol 1993; 7(2):211-214. Although in 1932 Crohn, Ginzburg and Oppenheimer noted recurrence in two of their 14 patients, they did not appreciate the remarkable propensity of this disease to recur following resection of all macroscopically diseased bowel. It was only later that the true panenteric nature of the disease was appreciated. Dunng the following three decades many believed that 'radical resection' wmild cure the disease, but subsequent studies showed that this was fallacious. Three types of recurrent Crohn's disease may be Jefined: symptomatic, recurrence recognized by pathological, radiological or endoscopic techniques ( true recurrences); and operative. On! y recurrences confinned by endoscopy, and gross and microscopic pathology should be accepted as true recurrent disease. Many factors influence postoperative recurrence rates. All series studied ac-tuarially show a steady increase in calculated recurrence rates with time (which is the major and dominant factor). Other factors which increase recurrence rares are anatomic localization (ilea! or ileocolonic), type of operation performed (bypass versus resection), and multiple resections. Factors which probably in-fluence races arc long segment disease, second reoperation, perforating disease, and young age at onset. Factors which possibly influence rates are overt disease at the resection margins and female sex. The presence of microscopic or macro-scopic disease at the resection margins, and the amount of normal-appearing howel removed do not appear to affect rates of recurrence. Following stric-tureplasty recurrence rates arc at least as high as following resection.

Key Words: Crohn's disease, Recurrence, Recurrence rates, Posroperative recur-rence, Stricmreplasry

Recurrence de la maladie de Crohn

RESUME: Bien qu'en 1932 Crohn, Ginzburg et Oppenheimer aient note une recurrence chez deux de leurs 4uarorze patients, ils n'ont pas mesurc la rcmarqua-ble propension de cette maladie a recidiver suite a la resection de toutes les portions d'intestin affectees macroscopiqucmcnt. Ce n'cst que plus tard que la veritable nature panenterique de la maladie a ere appreciec a sa juste valeur. Au cours des trois decennies suivantes, plusieurs ont cru que la resection radicale serait la solution, mais des etudes subsequences ont infirme cette hypothese. T rois types de maladie de Crohn recidivantcs sont definis: syrnptomatique, c'esr-a-dire quc les rccidives sont reconnues par des techniques anatomo-pathologiques, radiologiques ou endoscopiques (recurrences vraies); et par la chirurgie. Seules les recurrences confinnees par endoscopie et par l'anatomo-pathologie macro-

Profe5sor of Surger:v, The Moun( Sinai School of Medicine of the City Unit•L>r.my of New York, New York, New York, USA

Comis/>ondence and reprinL1: Dr N Green.1Cem, Muun( Smai Medical Center, Department of Surgery. One Gustat•e L Lev)• Place, Neu, York, NY /0029, USA

CAN] GASTROENTERL)L VOL 7 No 2 FEBRUARY 1993

CROI IN ET AL (I) IN T l IEIR INITIAL paper in 1932 on regional ileitis, noted that recurrent disease occurred in two of their L 4 patients. In the years that followeJ it became evident that the most common postoperative sequel of Crohn 's disease was recurrent ileitis, most frequently affecting the neoter-minal ileum just proximal to or at the anastomosis. Many factors influence postoperative recurrence rares. impor-tant among the surgical considerations are anatomic localization, type of operation performeJ (bypass versus resection, or complete versus staged procedures), the length of bowel in-volved, presence of microscopic or macroscopic disease at the resection margins, and amount of normal-appearing bowel removed.

It is generally accepted that the rate of postoperative recurrence is high in Crohn's Jisease involving only or mainly the small bowel. The question of recurrence in Crohn's colitis in which the disease is confined to the large bowel remains controversial. There is considerable variation, how-ever, in reported recurrence rates for all types of inflammacory bowel disease (lBD) , reflecting the differences in patient populations, referral patterns, ways of defining recurrent disease, methods of calculating recurrence rates, operative procedures and lengths of follow-up.

The diagnosis of primary and recur-rent Crohn's Jisease in the sympto-matic patient has classically been established by radiological methods (2) but thickened narrow bowel can also he

Z 11

GREEN~TEIN

scopique et microscopique Jevraienc etre acceptees comme signcs d'une recurrence reelle de la maladie. Plusieurs facteurs influent sur les raux de recurrence post-operaroire. Toutes les series etudiees par metho

sparing the rectum, Korel1cz (1 2) found distal spread to the rectum in 4 3 (39°,,{,), proximal spread in 39 (35%), prox imal and dista l spread in 16 (14%) and no spread in 16 04'}6 ). In ileocolins or colitis, therefore, distal recurren ce is as common a~ proximal recurre nce, whereas in ile itis, proxima l recurren ce is considerably more common . A l-though a number of studies suggcsL an inverse relationship between recur-rence a nd preoperati ve durnrinn of dis-ease - the shorte r the duration , the highe r the recurre nce ra te - t his has not bee n confirmed.

In an outstanding study hy Rutgecrts et al ( 4) on 89 pau ents studied pre-opera tively and examined e ndoscop1-cally in t he postoperative pe riod, the ultima te course of the disease was best predic ted by the early postoperative lesion s observed at ileoscopy. C linical factors which influen ced outcome were preoperative disease activity, surgical indication , and number of surgical resections.

RECURRENCE FOLLOWING STRICTUREPLASTY

There h as been considerable dif-fe rence of opinion among surgeons regarding resection of apparently nor-mal bowe l beyond the obviously d1s-caseJ segment. Lengths of variable extem h ave heen suggested. However, the findings of a study by Pennington c t al ( 13 ) did no t support the concept of radical howe l resection . These oh-

REFERENCES I. Cmhn BB, G inzhurg L, Oppenheimer

GD. Regional ilettis; a pathologic and clinical enLily. JAMA I 932;99: l323-9.

2. Marshak RI I, Lmdner AE. Ra.

5. Lennard-Jones JE, Stalder GA. Prognosis after resectinn of chrome regiomi l ileitis. Gut 1967;8:332-6.

6. G rcen~1ein AJ, S;ichar DB, Pastemak BS, Janowicz HD. Reopenition and

servers found no difference in recur-ren ce rates whether there was d isease at t he rescctilm margin. Lee ct a l ( 14) al~o re ported that there was no ~1gnificant diffe rence in the ttmcs o r frequenc ies of recurrence a mong 24 patients with ac-tive inflammat ion ur Lo the limit of resection and a s imilar number studied with no disease at the resection ma rgin. The ir reCt)mmcndation was, therefore, to carry out 'cnteroplasty' witho ut resection on r a t1ents with multiple areas of d isease. They cla imed satisfac-to ry results, wnh preservation ot as muc h bowe l as possihle using these nonresect iona l techniques. A recent 10 year fo llow-up from Oxford by Dehn ct al (l 5) supports the ir early posit ive re po rts; they found a reoperation rate of 16%, four of 24 patients requiring a furthe r 13 stric turcplastics. Sayfan ct a l (16) found that the s ite-specific opera-tion -free inte rval~ 111 41 pat iem s of 75% at five years were no t significantly differe n t from an equa l number treated by sma ll bowel resection . However they used strictureplasty and n ot patients as the den ommator in the former group. In a series of 27 strictureplasty patients subjected to 126 strictureplasties car-ried out by this author e igh t required reoperation (two were for cancer, three for new stric tures, and three for per-forating complicat ions). Actua rially calculated reoperation rates were at least as high as for sma ll bowel resec-tion. A mo1,t i.ntercsting aspect of this type of surgery is t he relatively infre-

7.

8.

9.

IO.

recurrence m Crohn's coli tis and ileocoli11s: Crude and cumulalive rares. N Engl J Med J 975;293:685-90. Sachar DB, Wolfson OM, Greenstein AJ, GnldbergJ, Styczynski R, J,mown: HD. Risk factors for postoperative recurrence of Crohn 's disease. Gastrocnterology I 983;85:9 L 7-2 1. DeDomhal FT, Burton IL, Goligher JC. Recurrence of Crnhn's d15ease ;iftcr pnmary excisional surgery. C ut 197!;12:519-27. Greenstein AJ, Lachman P, Sachar DB, et al. Perfornrmg and nonperforaring ind1cau,ins for repeated ,,perat inns in Cmhn's d1sea,c: Ev1Jence for tw0 clinical fmms. n ut L 988;29:588-92. H11na l HS, Bell1veaup. Prngnnsi~ niter surgical treatment for granul0matous entcm1s and colit is. Am J Surg

CAN J GASTROFNTERm VOL 7 No 2 FrnRUARY J 993

Recurrence in Crohn's disease

q ue nt occurrence of recurrent st rictures at origina l st ricturcplasty sites, occur-nng in approx imately 2°1

GREENSTEIN

Mortenson NJMcC, the late Lee ECG Jewell DP. Ten year experience of stricrureplasty for obstructive J1sease. Br J Surg 1989; 76:339-41.

16. Sayfan J , Wi lson DAL, Andrews AAH, A lexanJer-WilliamsJ. Recur-rence after strictureplasty for Crohn's disease. Br J Surg. 1989;76:335-8.

17. Fazio VW, Galan

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Recurrence in Crohn's disease - Hindawi Publishing Corporationmethods are used to correct for varrn tions m follnw-up inrerval. Most authors find no difference in recurrence rates