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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 1  |  Page : 1-3

Surgical strategies to reduce recurrence in Crohn's disease


Division of Colon and Rectal Surgery, Icahn School of Medicine at Mount Sinai, New York, USA

Date of Web Publication12-Mar-2019

Correspondence Address:
Dr. Randolph M Steinhagen
Division of Colon and Rectal Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1259, New York 10029
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/WJCS.WJCS_1_17

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  Abstract 

Almost from the time of initial description of Crohn's disease 85 years ago, it has been known that surgical resection is not curative. The disease invariably recurs. Over this period of time, numerous strategies have been proposed in an attempt to reduce the recurrence rate, or delay the development of recurrent disease. The purpose of this review is to examine a number of strategies and to evaluate their effectiveness. It also aims to look at what might lie ahead in the future. This review consists of an English language literature search to identify previous studies that have proposed various surgical strategies to reduce the recurrence rate following surgery for Crohn's disease. A number of surgical strategies have been proposed including widening the resection margins, changing the type of anastomosis, use of laparoscopy, and most recently, resecting wide mesenteric margins. To date, none of these strategies has proven to be effective in reducing recurrence rates. Although a surgical strategy to reduce recurrence in Crohn's disease has not been identified, there are currently investigators looking at other possibilities that may be shown to be effective in the future.

Keywords: Crohn's disease, recurrence, surgery


How to cite this article:
Austin C, Steinhagen RM. Surgical strategies to reduce recurrence in Crohn's disease. World J Colorectal Surg 2019;8:1-3

How to cite this URL:
Austin C, Steinhagen RM. Surgical strategies to reduce recurrence in Crohn's disease. World J Colorectal Surg [serial online] 2019 [cited 2019 Oct 14];8:1-3. Available from: http://www.wjcs.us.com/text.asp?2019/8/1/1/254033


  Introduction Top


Crohn's disease was first described at the Mount Sinai Hospital by Crohn, Ginzburg, and Oppenheimer, in an article entitled, “Regional Ileitis,” published in the Journal of the American Medical Association in 1932.[1] The article described 14 patients who had been operated on by the chief gastrointestinal (GI) surgeon, Dr. AA. Berg, at the hospital. All the patients exhibited ulcerative, granulomatous inflammation of the terminal ileum; the authors described thickened, fibrotic mesentery with a tendency to form abscesses and internal fistulas. Symptomatically, patients exhibited fever, weight loss, diarrhea, abdominal pain, and anemia, similar to the previously described ulcerative colitis. The authors recommended surgical resection of the diseased portion of the ileum and the adjacent ileocecal valve and cecum, with re-anastomosis of the proximal ileum to the transverse colon. They reported that this operation was “curative” in 13 out of 14 cases, though there were hints of the now well-understood difficulties in the surgical management of Crohn's disease; one patient experienced disease recurrence proximal to the anastomosis.

Unlike ulcerative colitis, which affects only the colon from ileocecal valve to the rectum, Crohn's disease can affect any portion of the GI tract. Therefore, while surgery may be necessary to manage the symptoms and complications of Crohn's disease, it is never curative. Up to 80% of patients with Crohn's disease will require surgery within 10 years of symptom onset.[2] Within 1 year of surgery, up to 90% of patients will have endoscopic evidence of recurrent disease, and within 3 years, the same proportion will have symptomatic recurrence.[3] Up to 80% of patients will require a second surgery within 15 years.[4],[5]


  Early Surgical Management Top


Initially, surgery was understood to be the best treatment for Crohn's disease. A retrospective study from the Lahey Clinic in 1960, of 300 patients with Crohn's disease treated with surgery, found low rates of recurrence, even in patients who required multiple surgeries for initial recurrence. The authors, Colcock and Vansant, described 14 types of surgical procedures, including ileocolic resection, small-bowel resection, appendectomy, and fistulotomy. They reported, “This study indicates that radical extirpation of the organs involved in regional enteritis offers a good chance for recovery, with a minimal operative risk. Even patients who require a second or third resection have a better than 50% chance of remaining well.”[6] Subsequently, recurrence rates were found to be much higher. A retrospective study from Mount Sinai Hospital in 1975, which used improved statistical methodology and took into account differences in the length of follow-up and differences in operative procedures, found that approximately 80% of patients required re-operation within 15 years.[5] A study from the Cleveland Clinic a few years later suggested that 42% of patients would require re-operation within 10 years.[7] There have been numerous strategies suggested in an attempt to influence the recurrence rate and reduce the need for additional surgery.


  Wide Versus Narrow Resection Margins Top


Many observers noticed that recurrence was most likely to occur at the site of the anastomosis, specifically on the proximal side.[8] In 1984, researchers from the University Hospital, Leuven in Belgium, looked at endoscopic recurrence in 114 patients and found that recurrence occurred at the site of the anastomosis in 88% of patients.[9] This phenomenon suggested that wide resection margins might reduce disease recurrence, allowing for surgeons to resect microscopically diseased bowel that had not yet progressed to gross disease. Throughout the late 1970s and early 1980s, retrospective studies stressed the importance of wide, microscopic disease-free margins in resection for Crohn's disease,[10],[11] while others disputed this idea, cautioning against the resection of grossly normal bowel.[12]

A more definitive answer came from a randomized prospective trial published in 1984. A total of 152 patients at the Cleveland Clinic were randomized into two groups: in one group, the proximal line of resection was 2 cm from the grossly diseased bowel, and in the other, transection was done 12 cm proximal to the grossly involved margin. The findings were that disease recurrence was similar in the two groups, unaffected by the presence of microscopic disease at the resection margins.[13]


  Extent of Colonic Excision Top


In 1985, Goligher, at the University of Leeds, described the long-term outcomes for nearly 300 patients with Crohn's colitis who underwent colonic resection. Patients who underwent ileostomy with colectomy or proctocolectomy had far less disease recurrence (15%) than patients who underwent colectomy with ileorectal anastomosis (71%).[14] A more recent prospective study showed similar benefits to a more aggressive approach to Crohn's colitis: patients undergoing total proctocolectomy had a significantly lower risk of recurrence and longer time to recurrence. They were more likely to be independent of Crohn's medications within a year of surgery than patients undergoing segmental colectomy.[15] Thus, though a more conservative approach is favored in small-bowel disease, a more aggressive approach in isolated Crohn's colitis may have long-term benefits.


  Laparoscopic Versus Open Surgery Top


Laparoscopic surgery for Crohn's disease was first described in 1993.[16] In the late 1990s, the advantages of laparoscopy in GI surgery began to be recognized. Patients undergoing laparoscopic surgery were found to have potentially faster recovery times, shorter hospital stays, and decreased pain. Furthermore, laparoscopic surgery was found to be associated with decreased adhesion formation, which could be especially beneficial in Crohn's patients, as inflammation in Crohn's disease can itself cause adhesions, and reoperation is common. Perioperative benefits have been reported in Crohn's disease: a meta-analysis in 2006 showed that patients undergoing laparoscopic resection for ileocecal disease had faster return of bowel function and shorter hospital stays than patients undergoing open resection.[17] However, the reduced ability to directly visualize the bowels in laparoscopic surgery led to the hypothesis that laparoscopic surgery may lead to increased clinical recurrence as diseased bowel may be more likely to be left behind. However, a meta-analysis found no significant difference in disease recurrence, or adhesive small-bowel obstruction between laparoscopic and open resections for ileocolic disease.[18] Therefore, while there may be benefits to laparoscopic surgery for Crohn's disease patients in the short term, in the long term, neither method has been shown to be superior. There are still no randomized controlled trials which compare the two methods.


  Type of Anastomosis Top


Researchers hypothesized that the type of anastomosis may have an impact on disease recurrence. This was supported by the observations that patients with end ileostomies had lower rates of recurrence than those with anastomoses,[19] and that infusion of intestinal contents through the anastomosis of patients with ileocolic resections with ileocolonic anastomosis and diverting loop ileostomy could trigger disease recurrence.[20] Researchers hypothesized that narrower anastomoses could increase fecal stasis and thus increase recurrence. Numerous observational studies in the late 1990s and early 2000s compared side-to-side anastomosis with end-to-end anastomosis.[21],[22],[23],[24]

A meta-analysis in 2007 suggested that there was no difference in recurrence rates based on anastomotic configuration.[25] These data were further supported by the results of a randomized controlled trial from the University of Toronto in 2009, which found no difference between recurrence rates in end-to-end versus side-to-side anastomosis.[26]

More recently, researchers in Japan have promoted the use of a novel type of anastomosis, known as the Kono-S anastomosis. The Kono-S anastomosis is a hand-sewn, end-to-end anastomosis that uses the staple lines from the resected margins as a supporting column for the anastomosis. A retrospective study published in 2016 showed that, of 187 patients who received surgery for Crohn's disease with a Kono-S anastomosis in Japan, only two required re-operation at the anastomotic site, with a median follow-up of about 5 years. The researchers hypothesized that the structure of the anastomosis helps maintain the patency of the lumen at the anastomotic site, and furthermore better preserves the blood supply and innervation of the anastomosis, promoting better healing.[27] The results of this study are promising, but further investigation, with longer follow-up, is necessary.


  Conclusion Top


As is the case in other diseases that are more commonly seen in industrialized countries of the world, the incidence of both Crohn's disease and ulcerative colitis is increasing. In the United States, the medical cost of inflammatory bowel disease exceeded $6 billion in 2004.[28] Nearly 85 years after it was first described, Crohn's disease remains a poorly understood disease. Although numerous strategies have been employed in an attempt to reduce disease recurrence after surgery, none, to date, have been proven effective. Further study aimed at better understanding the pathogenesis of Crohn's disease is necessary in order to improve medical and surgical treatments for the disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Crohn BB, Ginzburg L, Oppenheimer GD. Regional ileitis. JAMA 1932;99:1323-8.  Back to cited text no. 1
    
2.
Bernell O, Lapidus A, Hellers G. Risk factors for surgery and recurrence in 907 patients with primary ileocaecal Crohn's disease. Br J Surg 2000;87:1697-701.  Back to cited text no. 2
    
3.
Olaison G, Smedh K, Sjödahl R. Natural course of Crohn's disease after ileocolic resection: Endoscopically visualised ileal ulcers preceding symptoms. Gut 1992;33:331-5.  Back to cited text no. 3
    
4.
Whelan G, Farmer RG, Fazio VW, Goormastic M. Recurrence after surgery in Crohn's disease. Relationship to location of disease (clinical pattern) and surgical indication. Gastroenterology 1985;88:1826-33.  Back to cited text no. 4
    
5.
Greenstein AJ, Sachar DB, Pasternack BS, Janowitz HD. Reoperation and recurrence in Crohn's colitis and ileocolitis crude and cumulative rates. N Engl J Med 1975;293:685-90.  Back to cited text no. 5
    
6.
Colcock BP, Vansant JH. Surgical treatment of regional enteritis. N Engl J Med 1960;262:435-9.  Back to cited text no. 6
    
7.
Lock MR, Farmer RG, Fazio VW, Jagelman DG, Lavery IC, Weakley FL, et al. Recurrence and reoperation for Crohn's disease: The role of disease location in prognosis. N Engl J Med 1981;304:1586-8.  Back to cited text no. 7
    
8.
Farmer RG, Hawk WA, Turnbull RB Jr. Clinical patterns in Crohn's disease: A statistical study of 615 cases. Gastroenterology 1975;68:627-35.  Back to cited text no. 8
    
9.
Rutgeerts P, Geboes K, Vantrappen G, Kerremans R, Coenegrachts JL, Coremans G, et al. Natural history of recurrent Crohn's disease at the ileocolonic anastomosis after curative surgery. Gut 1984;25:665-72.  Back to cited text no. 9
    
10.
Wolff BG, Beart RW Jr., Frydenberg HB, Weiland LH, Agrez MV, Ilstrup DM, et al. The importance of disease-free margins in resections for Crohn's disease. Dis Colon Rectum 1983;26:239-43.  Back to cited text no. 10
    
11.
Bergman L, Krause U. Crohn's disease. A long-term study of the clinical course in 186 patients. Scand J Gastroenterol 1977;12:937-44.  Back to cited text no. 11
    
12.
Pennington L, Hamilton SR, Bayless TM, Cameron JL. Surgical management of Crohn's disease. Influence of disease at margin of resection. Ann Surg 1980;192:311-8.  Back to cited text no. 12
    
13.
Fazio VW, Marchetti F, Church M, Goldblum JR, Lavery C, Hull TL, et al. Effect of resection margins on the recurrence of Crohn's disease in the small bowel. A randomized controlled trial. Ann Surg 1996;224:563-71.  Back to cited text no. 13
    
14.
Goligher JC. The long-term results of excisional surgery for primary and recurrent Crohn's disease of the large intestine. Dis Colon Rectum 1985;28:51-5.  Back to cited text no. 14
    
15.
Fichera A, McCormack R, Rubin MA, Hurst RD, Michelassi F. Long-term outcome of surgically treated Crohn's colitis: A prospective study. Dis Colon Rectum 2005;48:963-9.  Back to cited text no. 15
    
16.
Milsom JW, Lavery IC, Böhm B, Fazio VW. Laparoscopically assisted ileocolectomy in Crohn's disease. Surg Laparosc Endosc 1993;3:77-80.  Back to cited text no. 16
    
17.
Tilney HS, Constantinides VA, Heriot AG, Nicolaou M, Athanasiou T, Ziprin P, et al. Comparison of laparoscopic and open ileocecal resection for Crohn's disease: A metaanalysis. Surg Endosc 2006;20:1036-44.  Back to cited text no. 17
    
18.
Patel SV, Patel SV, Ramagopalan SV, Ott MC. Laparoscopic surgery for Crohn's disease: A meta-analysis of perioperative complications and long term outcomes compared with open surgery. BMC Surg 2013;13:14.  Back to cited text no. 18
    
19.
Scammell B, Ambrose NS, Alexander-Williams J, Allan RN, Keighley MR. Recurrent small bowel Crohn's disease is more frequent after subtotal colectomy and ileorectal anastomosis than proctocolectomy. Dis Colon Rectum 1985;28:770-1.  Back to cited text no. 19
    
20.
D'Haens GR, Geboes K, Peeters M, Baert F, Penninckx F, Rutgeerts P, et al. Early lesions of recurrent Crohn's disease caused by infusion of intestinal contents in excluded ileum. Gastroenterology 1998;114:262-7.  Back to cited text no. 20
    
21.
Tersigni R, Alessandroni L, Barreca M, Piovanello P, Prantera C. Does stapled functional end-to-end anastomosis affect recurrence of Crohn's disease after ileocolonic resection? Hepatogastroenterology 2003;50:1422-5.  Back to cited text no. 21
    
22.
Scarpa M, Angriman I, Barollo M, Polese L, Ruffolo C, Bertin M, et al. Role of stapled and hand-sewn anastomoses in recurrence of Crohn's disease. Hepatogastroenterology 2004;51:1053-7.  Back to cited text no. 22
    
23.
Hashemi M, Novell JR, Lewis AA. Side-to-side stapled anastomosis may delay recurrence in Crohn's disease. Dis Colon Rectum 1998;41:1293-6.  Back to cited text no. 23
    
24.
Yamamoto T, Bain IM, Mylonakis E, Allan RN, Keighley MR. Stapled functional end-to-end anastomosis versus sutured end-to-end anastomosis after ileocolonic resection in Crohn's disease. Scand J Gastroenterol 1999;34:708-13.  Back to cited text no. 24
    
25.
Simillis C, Purkayastha S, Yamamoto T, Strong SA, Darzi AW, Tekkis PP, et al. Ameta-analysis comparing conventional end-to-end anastomosis vs. other anastomotic configurations after resection in Crohn's disease. Dis Colon Rectum 2007;50:1674-87.  Back to cited text no. 25
    
26.
McLeod RS, Wolff BG, Ross S, Parkes R, McKenzie M; Investigators of the CAST Trial, et al. Recurrence of Crohn's disease after ileocolic resection is not affected by anastomotic type: Results of a multicenter, randomized, controlled trial. Dis Colon Rectum 2009;52:919-27.  Back to cited text no. 26
    
27.
Kono T, Fichera A, Maeda K, Sakai Y, Ohge H, Krane M, et al. Kono-S anastomosis for surgical prophylaxis of anastomotic recurrence in Crohn's disease: An international multicenter study. J Gastrointest Surg 2016;20:783-90.  Back to cited text no. 27
    
28.
Kaplan GG. The global burden of IBD: From 2015 to 2025. Nat Rev Gastroenterol Hepatol 2015;12:720-7.  Back to cited text no. 28
    




 

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  In this article
Abstract
Introduction
Early Surgical M...
Wide Versus Narr...
Extent of Coloni...
Laparoscopic Ver...
Type of Anastomosis
Conclusion
References

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