AVOIDING A STOMA - ROLE FOR SEGMENTAL OR ABDOMINAL COLECTOMY IN CROHNS COLITIS

Total proctocolectomy and ileostomy for Crohn's colitis offers a low r ecurrence rate but commits patients to a permanent ileostomy. In contr ast, segmental resection may predispose patients to recurrence and fur ther surgery but may delay or avoid a stoma in select individuals. AIM : This study was undertaken to determine the risk of recurrence and th e need for permanent stoma in patients treated with segmental or abdom inal colectomy for Crohn's colitis. METHODS: Between 1976 and 1985, 69 9 patients underwent surgery for Crohn's colitis at the Mayo Clinic. P atients who had a total proctocolectomy and end ileostomy or primary i leal or anorectal disease were excluded from further study. Fifty-thre e patients had a colon resection without a permanent stoma, and 43 wer e alive and available for follow-up. During a mean follow-up of 14 yea rs, completed questionnaires provided current details on subsequent me dical and surgical therapies and/or stomas that were required. In thes e 49 patients, Crohn's of the colon involved the right, left, and both sides of the colon in 12, 31, and 6 patients, respectively, and invol ved less than one-third, one to two-thirds, and greater than two-third s of the colon in 23, 25, and 1 patients, respectively. RESULTS: Twent y-two of forty-nine patients (45 percent) required no further therapy. In 27 patients (55 percent), further treatment was required, includin g 11 (22 percent) patients who were managed medically (only 4 >1 year) and 16 (33 percent) patients who were managed surgically. Three recur rences developed in the small bowel; the remaining 24 developed in the colon. For the 16 patients with recurrence requiring surgery, mean ti me to recurrence was 51 +/- 14 months; in all cases, recurrent disease involved the colon, with four anastomotic recurrences. At first recur rence, ten patients underwent another limited colon resection, and six patients underwent completion proctectomy with permanent ileostomy. F ive patients required a third procedure, only one of which resulted in a permanent ileostomy. Therefore, 42 patients (86 percent) remained s toma-free, and 7 (14 percent) ultimately required permanent ileostomy, with a mean stoma-free interval of 23 +/- 4 months. CONCLUSION: Colon resection without proctectomy in select patients with limited colonic Crohn's disease can delay or avoid the necessity of a permanent stoma .