Crohn's disease - Outcome of surgery

Although medical therapy is the primary method of treatment for patients wi th Crohn's disease, approximately 80% of affected patients will require sur gery at some time. Surgery is usually effective in eliminating the complica tions of the disease and improving quality of life. However, the disease of ten recurs in a large proportion of patients and requires further medical a nd even surgical therapy. In the literature, recurrence rates of 3.4-16% pe r year have been reported depending on the criteria used to define recurren ce. Various surgical maneuvers do not seem to decrease this recurrence rate and will be addressed below. Certain drugs may be effective as maintenance therapy and now such drugs as the 5-aminosalicylic acid (5-ASA) compounds and azathioprine have been shown to have some effect in maintaining remissi on following surgery. We undertook a randomized, multicenter, controlled tr ial to determine whether 5-ASA was effective in reducing the risk of recurr ent Crohn's disease in patients who had had a surgical resection. Within 8 weeks of surgery, 163 patients who had no evidence of gross residual diseas e were randomized to a group administered 1.5 g 5-ASA twice daily, or to a placebo control group. All patients underwent follow-up endoscopic or radio logical investigations. Symptomatic recurrence was defined as the presence of symptoms plus radiological or endoscopic evidence of redurrence. The sym ptomatic recurrence rate in the treatment group was 31% vs. 41% in control group (p = 0.031). The relative risk of developing recurrent disease was 0. 628 for those in the treatment group. The endoscopic/radiological rate of r ecurrence was also significantly decreased with relative risks of 0.654 in the effectiveness analysis and 0.635 in the efficacy analysis. In was concl uded that 5-ASA 3 g/day is effective in decreasing the risk of recurrence o f Crohn's disease following surgical intervention. A subgroup analysis perf ormed to assess the effect of treatment according to the site of disease sh owed that there was a positive treatment effect in the following three subg roups: those with small bowel disease alone, those with small and large bow el disease, and those with large bowel disease alone. The smallest treatmen t effect was observed in patients with disease limited to their small bowel and the largest for those with disease limited to their large bowel. We th en undertook a retrospective review of potential operative and environmenta l risk factors for Crohn's disease recurrence and examined whether a handse wn or a stapled anastomosis led to a greater recurrence rate in patients un dergoing ileocecal resection for terminal ileal Crohn's disease. The effect s of oral contraceptive use, smoking, and the age at onset of disease were also examined. Ninety-two patients whose first operation was an ileocecal r esection were studied for symptomatic and operative recurrence. The symptom atic recurrence rates were 15% at 1 year, 31% at 2 years and 45% at 3 years . The operative recurrence rates were 6% at 1 year, 14% at 2 years, and 22% at 3 years. The type of anastomosis, whether hand-sewn or stapled, did not affect the rates of symptomatic or operative recurrence. After the initial resection, smoking affected both symptomatic (p = 0.03) and operative (p = 0.04) recurrence, but age at onset of disease or oral contraceptives use s howed no effect. Other studies have substantiated the effect of smoking. Th e type of anastomosis, whether it be end to end, or side to side, or end to side and the type of material used, be it stapling or sutures, did not inf luence the recurrence rate as has been suggested by other reports. (C) 2000 Prous Science. Alt rights reserved.