SURGERY IN CROHNS-DISEASE - WHEN, WHERE AND WHY THE RECURRENCES

One frustrating feature in the surgical management of Crohn's disease is the high recurrence rate which may lead to reoperation. It is commo n opinion that relapses occur haphazardly both in time and in site, an d the causes remain unknown. When does a recurrence really arise after surgery? Is the site of recurrence determined by definite causes? Is there a relapsing factor? Between 1965 and 1995, 177 patients underwen t surgery for Crohn's disease. The procedures performed in 145 cases w ere those popular at the time, while a recent series of 20 selected pa tients was managed following a new approach based on epiploonplasty. T his strategy stems from the strong conviction that Crohn's disease is not a primary bowel disease but the result of stasis and superimposed infection due to a primary hemolymphatic disorder of the mesentery. Th e five-year recurrence rate was 62% in patients operated on according to standard procedures, while no recurrences were reported in the epip loonplasty group. Among 12 remaining patients with recurrent disease, two cases are reported in detail because they provide evidence in favo r of the hemolymphatic theory.This study also maintains that recurrenc es, viewed with the hemolymphatic disorder in mind, occur immediately after surgery, while the superimposed intestinal inflammatory process and stricturing events may appear clinically at different time interva ls during follow-up. The site of recurrences usually corresponds to th e mesenteric region subjected to compression. Altered mesenteric micro circulation appears to be the true essence of the disease.