Long-term results and multivariate analysis of prognostic factors in 138 consecutive patients operated on for Crohn’s disease using “bowel-sparing” techniques

doi:10.1016/S0002-9610(00)00334-2

The American Journal of Surgery

Volume 179, Issue 4, April 2000, Pages 266-270

https://doi.org/10.1016/S0002-9610(00)00334-2 Get rights and content

Abstract

Background: Conservative surgery has become accepted as a useful option for the surgical treatment of complicated Crohn’s disease (CD).

Methodts:

One hundred thirty-eight consecutive patients treated with strictureplasty or miniresections for complicated CD have been observed prospectively. The possible influence of a number of variables on the risk of recurrence was investigated using the Cox proportional hazard model, and a time-to-event analysis was made using the Kaplan-Meier function.

Results: There was no perioperative mortality; the morbidity rate was 5.7%. A close correlation was found between the risk of recurrence and the time between diagnosis and first surgery. The overall 5-year recurrence rate was 24%, being 36% in the patients requiring surgery within 1 year of diagnosis and 14% in those operated on more than 1 year after diagnosis.

Conclusions: Risk factor analysis highlighted a group of patients at high risk of surgical recurrence. Given that our results are similar to those reported in other series, we consider strictureplasty and miniresections safe and effective procedures for the treatment of complicated CD.

Section snippets

Patients and methods

Between January 1993 and January 1999, 138 consecutive patients underwent surgery for complicated or treatment-refractory CD at the Department of Surgery of “Luigi Sacco” University Hospital, Milan, Italy. At the time of admission, a careful clinical history was taken, including age, gender, family history of CD, age at diagnosis, age at first surgery, time between first surgery and diagnosis, duration and site of CD, and type of previously performed surgery. The patients were subsequently

Results

The 138 patients included 82 men and 56 women; 8 patients (5.7%) had a positive family history of CD, and 62 patients (45%) had undergone one or more previous bowel resections in other institutions. The mean ages at diagnosis, first surgery, and our surgery were, respectively, 31.6 ± 11.2, 32 ± 11.3, and 39 ± 12.1 years. The mean time between diagnosis and first surgery was 4.1 ± 5.3 years, and that between the first and second surgery was 7.6 ± 5.8 years. The mean disease duration was 7.3 ± 6

Comments

Surgery cannot be considered as definitive treatment for Crohn’s disease, because the long-term surgical recurrence rate is as high as 30% to 60% at 5 to 10 years.12, 13, 14, 15 The natural history of the disease, the use of various criteria and definitions in published series, and the lack of prospective, randomized trials are reasons for the different interpretations of prognostic factors.7, 14 In clinical practice, it is therefore difficult to identify patients at high risk of early surgical

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For colonic resections, vascular control was obtained at major trunks, and not close to the bowel wall. At the end of the surgical procedures, the operating surgeon completed a special form with all intraoperative data and the patient was inserted in the CD-CARD upon discharge from the hospital [9,12,16,17]. Since no agreement nor a classification was present in the literature for mesentery thickening of CD patients, the mesentery, tributary of a diseased bowel segment, was arbitrarily classified as thickened when the thickness was more than 5 mm, and/or when the wrapping fat involved more than 180° of bowel girth, with vascular and lymphatic retraction.
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This study provides new information on mesentery and lymphnodes in CD patients. Further studies are needed to clarify the appropriate surgical approach.
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Laparoscopy is considered the best surgical approach for Crohn's Disease (CD), and strictureplasty a reliable alternative to intestinal resection. Nevertheless, their association has never been evaluated.
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Between January 2008 and December 2019, 331 patients received 162 SPs, 138 NCSPs, and 373 resections (Group-A). From the CD-CARD, 227 control patients received 159 SPs, 117 NCSPs, and 271 resections (Group-B) (ns). Preoperatively, Group-A presented batter nutritional status and received more biological therapies, Group-B more steroids. Group-A presented less abdominal abscesses, planned ostomies, minor complications, shorter operating time and hospitalization than Group-B, but similar major complications, IASCs and anastomotic leaks. IASCs were related to older age, elevated inflammatory indices, and preoperative treatment with high-risk drugs.
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Strictureplasty is an alternative to resection for treatment of Crohn’s disease (CD) strictures. It preserves bowel length, and specialized centers report favorable outcomes. Strictureplasty rates, however, are thought to be low, and it was recently removed from required cases for colon and rectal surgery residents. We examined operative characteristics, and trends in its use using a large national database.
We examined the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2012, identifying patients with CD who underwent strictureplasty. We identified patient characteristics, outcome variables, and trends in utilization of strictureplasty.
A total of 9172 patients underwent surgery for CD. Two hundred fifty-six (2.8 %) underwent strictureplasty. Median preoperative albumin was 3.6. Preoperative steroid use and weight loss rates were 39 and 8 %. Rates of wound infection and organ space infection were 11 and 4 %. Rate of reoperation was 6 %. Outcomes did not change significantly over time (all p = NS). The proportion of CD operations that included a strictureplasty decreased from 5.1 to 1.7 % (OR 0.902 with each additional year, 95 % CI (0.852, 0.960), p < 0.001).
Strictureplasty as treatment for CD is decreasing in the ACS-NSQIP database. Infectious complications and reoperation rates following strictureplasty are low and have not changed over time.
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Epidemiology and natural history of inflammatory bowel diseases
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Long-term results and multivariate analysis of prognostic factors in 138 consecutive patients operated on for Crohn’s disease using “bowel-sparing” techniques

Abstract

Section snippets

Patients and methods

Results

Comments

Lancet

Gastroenterology

Gastroenterology

Gastroenterology

Am J Surg

Mayo Clin Proc

Microgranulomas in grossly normal rectal mucosa in Crohn’s disease

Am J Clin Pathol

Enzymatic and morphometric evidence for Crohn’s disease as a diffuse lesion of the gastrointestinal tract

Gut

The small-intestinal mucosa in patients with Crohn’s disease assessed by scanning electron and light microscopy

Scand J Gastroenterol

Perforating and non-perforating indications for repeated operations in Crohn’s diseaseevidence for two clinical forms

Gut

Patterns of postoperative recurrence in Crohn’s disease

Scand J Gastroenterol

The impact of disease pattern, surgical management and individual surgeons on the risk for relaparotomy for recurrent Crohn’s disease

Ann Surg

Crohn’s disease. A long term study of the clinical course in 186 patients

Scand J Gastroenterol

Prognosis after recection of chronic regional ileitis

Gut

Reoperation and recurrence in Crohn’s colitis and ileocolitis

N J Med

The early and late results of surgical treatment of Crohn’s disease

Br J Surg

Factors affecting recurrence following resection for Crohn’s disease

Dis Colon Rectum

Crohn’s disease in Stockholm county, 1955–1974. A study of epidemiology, results of surgical treatment and long term prognosis

Acta Chir Scand