Year : 2019 | Volume
: 8 | Issue : 1 | Page : 1--3
Surgical strategies to reduce recurrence in Crohn's disease
Charlotte Austin, Randolph M Steinhagen
Division of Colon and Rectal Surgery, Icahn School of Medicine at Mount Sinai, New York, USA
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
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.
|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 2021 Sep 17 ];8:1-3
Available from: https://www.wjcs.us.com/text.asp?2019/8/1/1/254033
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. 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. 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. Up to 80% of patients will require a second surgery within 15 years.,
Early Surgical Management
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.” 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. A study from the Cleveland Clinic a few years later suggested that 42% of patients would require re-operation within 10 years. 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
Many observers noticed that recurrence was most likely to occur at the site of the anastomosis, specifically on the proximal side. 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. 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,, while others disputed this idea, cautioning against the resection of grossly normal bowel.
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.
Extent of Colonic Excision
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%). 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. 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
Laparoscopic surgery for Crohn's disease was first described in 1993. 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. 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. 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
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, 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. 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.,,,
A meta-analysis in 2007 suggested that there was no difference in recurrence rates based on anastomotic configuration. 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.
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. The results of this study are promising, but further investigation, with longer follow-up, is necessary.
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. 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.
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Conflicts of interest
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