Recurrence in Crohn's disease

AJ GREENSTEIN. Recurrence in Crohn's disease. Can J Gastroenterol 1993; 7(2):211-214. Although in 1932 Crohn, Ginzburg and Oppenheimer noted recurrence in two of their 14 patients, they did not appreciate the remarkable propensity of this disease to recur following resection of all macroscopically diseased bowel. It was only later that the true panenteric nature of the disease was appreciated. Dunng the following three decades many believed that 'radical resection' wmild cure the disease, but subsequent studies showed that this was fallacious. Three types of recurrent Crohn's disease may be Jefined: symptomatic, recurrence recognized by pathological, radiological or endoscopic techniques ( true recurrences); and operative. On! y recurrences confinned by endoscopy, and gross and microscopic pathology should be accepted as true recurrent disease. Many factors influence postoperative recurrence rates. All series studied actuarially show a steady increase in calculated recurrence rates with time (which is the major and dominant factor). Other factors which increase recurrence rares are anatomic localization (ilea! or ileocolonic), type of operation performed (bypass versus resection), and multiple resections. Factors which probably influence races arc long segment disease, second reoperation, perforating disease, and young age at onset. Factors which possibly influence rates are overt disease at the resection margins and female sex. The presence of microscopic or macroscopic disease at the resection margins, and the amount of normal-appearing howel removed do not appear to affect rates of recurrence. Following strictureplasty recurrence rates arc at least as high as following resection.

ble propension de cette maladie a recidiver suite a la resection de toutes les portions d'intestin affectees macroscopiqucmcnt.Ce n'cst que plus tard que la veritable nature panenterique de la maladie a ere appreciec a sa juste valeur.Au cours des trois decennies suivantes, plusieurs ont cru que la resection radicale serait la solution, mais des etudes subsequences ont infirme cette hypothese.T rois types de maladie de Crohn recidivantcs sont definis: syrnptomatique, c'esr-a-dire quc les rccidives sont reconnues par des techniques anatomo-pathologiques, radiologiques ou endoscopiques (recurrences vraies); et par la chirurgie.Seules les recurrences confinnees par endoscopie et par l'anatomo-pathologie macro- paper in 1932 on regional ileitis, noted that recurrent disease occurred in two of their L 4 patients.In the years that followeJ it became evident that the most common postoperative sequel of Crohn 's disease was recurrent ileitis, most frequently affecting the neoterminal ileum just proximal to or at the anastomosis.Many fac tors influence postoperative recurrence rares.important among the surgical considerations are anatomic localization, type of operation performeJ (bypass versus resection, or complete versus staged procedures), the length of bowel involved, presence of microscopic or macroscopic disease at the resection margins, and amount of normalappearing bowel removed.
It is generally accepted that the rate of postoperative recurrence is high in Crohn's Jisease involving only or mainly the small bowel.The question of recurrence in Crohn's colitis in which the disease is confined to the large bowel remains controversial.There is considerable variation, however, in reported recurrence rates for all types of inflammacory bowel disease (lBD) , reflecting the differences in patient populations, referral patterns, ways of defining rec urrent disease, methods of calculating recurrence rates, operative procedures and lengths of follow-up.
The diagnosis of primary and recurrent Crohn's Jisease in the sy mptomatic patient has classically been established by radiological methods (2) but thickened narrow bowel can also he Z 11 scopique et microscopique Jevraienc etre acceptees comme signcs d'une recurrence reelle de la maladie.Plusieurs facteurs influent sur les raux de recurrence post-operaroire.Toutes les series etudiees par metho<le actuarielle font etat d'une augmentation conscante des taux calcules de recurrence avec le temps (qui est le facteur principal et dominant).Parmi les autres facteurs qui contribuent a la hausse au taux de recurrence, notons le siege anatomique (ilea I ou ileocolique), le type d'operation effectuee (deviation versus resection) et les resections multiples.Les facteurs qui influent cgalement sur ces taux sont l'ctcnduc Jes lesions, la re-operation, la maladie perforame et le jeune age au debut de la maladie.Les facteurs qui influencent possiblement les taux sont la maladie avercc aux margcs des resections ct le fair d'etre de sexe feminin.La presence de maladie microscopiquc ou macroscopique aux marges de resection et la portion d'intestin d'apparence normale n~sequec ne scmblcnt pas influer sur !es taux de recidives.Suite a la plastic des portions retrccies, !es taux de recurrence sont au moins aussi clevcs que suite a la resection.apprec inte<l on computed tomography scan.Sites of recurrence may he seen endoscopically, provided I hey arc within reach of the colonoscnpc from he low or t he gasrroduodenoscope or entcroscope from above (3,4).W1ch these instruments, macroscopic changes (such as aphthous or frank ulcers) can be observed, biopsies can he taken nnd, on rare occasions, granulomas dcmonstraled, confi rming the presence of active Crohn's disease.

DEFINITION OF RECURRENT DISEASE
Lennard-Jones and Scalder (5) divided recurrences into recurrence uf clinical symptoms without evidence of new disease; recurrent symptoms wilh radiological and/or histological (endoscopic should be added today) proof of disease; and recurrent disease requiring further surgery.Rutgeerrs ct al ( 4) defining a high incidence of endoscop1call y recognizable recurrence (73% ar one year, of which only 20% were sympromauc), suggcstc<l that the ultimate course of the disease may be predicted by the severity of the ea rl y postoperative lcsiom ( 4 ).

METHODS OF ESTIMATING RECURRENCE
Many of the early discrepancies reponcd in the literature reflect the fact that the earliesl repons estimatcJ overa ll recurrence rates in a crude fashicm, simply noting the numher of recurrences occurring in the total group studied.
In 196 7, Lennard-Jones and Stalder ( 5) useJ actuarial methods incorporating the data obtamcd with progressive passage of time into an actuarial life-table .In 1975, the current authors (6) ex-amincJ several different factors influencing actuarially calculated recurrence rates and confirmed many of the earlier findings.Sachar ct al (7), using multivariate analysis, observed that the critical question is not only which factors influence recurrence rates, but which factors dn so in<lependently of other confounding influences.

FACTORS INFLUENCING RECURRENCE
DcDombal ct al (8) suggested that there were two types ofCrohn 's disease: an aggressive sort and a more slowly progressive type.We have studied a series of 770 patiems, among whom there appeared to he rwo different forms of Jiseasc.The perforating type appeared to he more aggressive anJ recurred sooner, while the nonperforating type recurred later (9).
A ll series studied actuarially show a steady increase in calculated recurrence rates with time which is the major and dominant factor in these rates.Ocher factors which influence: recurrence rares are ilea!or ilcocolonic disease, bypass and multiple resections.Factors which probably influence rates arc long segment disease, second reoperation, perforating disease and young age m ornet.Factors which possibly influence rares are overt disease at the resection margins and female sex.
Age appears w have an influence on the 1endency en recur.In almost all reports on the subject, the recurrence rntc has hecn consistently greater 111 younger age groups.This 111/luence oi age remains valid even when actuarial methods are used to correct for varrntions m follnw-up inrerval.Most authors find no difference in recurrence rates hetwcen men and women, although a considcrnhly poorer prognosis in women has heen noted (8).
The anatomic site of 111volvemenr helps to determine the likelihood of recurrence.High recurrence rates, hoth crude and actuarial, have been reponcJ for most ~cries of patients with regional ileitis following resection ( recurrence rates ranging from 42 to 86% at 15 years).Even higher rates follow bypas\ and there is liule controversy regarding recurrence in small btYwel disease.The question of recurrence in Crohn's colitis, in which the disease is initially confined to the colon, however, has engendered argument.Most observer, believe that patienn, with disease confined to the colon have a lower rme of recurrence than tht)Se in whom the terminal ileum is involved, although some have found no difference (10).There is agreement that recurrence fo llowing subtotal colc:c tomy and ilcorectal or ileos1gmo1d re-anastomosis 1s high.
The propensity of the proximal and distal segments of the gut to develop evidence of disease after an operative procedure has bearing on the problem of postoperative recurrence.Most authors report recurrences in rhe neotcrminal ileum just proximal to the suture line in patients with anastomosis or in the most disrnl ileum following ileostomy.Koch ct al ( 11) found that the site of recurrence was determined hy the site of primary disease.In ileitis, 100% of recurrences involved the proximal gut, 30% were both proximal and distal, anJ none was exclusively distal.Recurrences in ileocolitis patients developed proximally in 19%, distally in 19%, anJ both proximally and Jisrally in 62%.Thus, disease mitial ly confined to the terminal ileum may suhsequently progress to involve the colon fo llowing re~cction and rc-ana~tomosis.
Of 68 surgical ly treated cases of IBD sparing the rectum, Korel1cz (1 2) found distal spread to the rectum in 4 3 (39°,,{,), proximal spread in 39 (35%) , prox imal and dista l spread in 16 (14%) and no spread in 16 04'}6 ).In ileocolins or colitis, therefore, distal recurren ce is as commo n a~ proximal recurre nce, whereas in ile itis, prox ima l recurren ce is considerabl y mo re common .A lthough a number of studies suggcsL an inverse relationship between recurrence a nd preoperati ve durnrin n of disease -the shorte r the duration , the highe r the recurre nce ra te -t his has not bee n confirmed.
In an o utstanding study hy Rutgecrts et al ( 4) o n 89 pau ents studied p reopera ti vely and examined e ndoscop1cally in t he postoperati ve pe riod, the ultima te course o f the disease was best predic ted by the early postoperati ve lesion s observed at ileoscopy.C linical factors which influen ced outcome were preoperative disease activity, surg ical indicatio n , and number of surgical resectio ns.

RECURRENCE FOLLOWING STRICTUREPLASTY
There h as been considerable diffe rence of opinio n amon g surgeons regarding resectio n o f apparently normal bowe l beyond the obv io us ly d1s-caseJ segment.Len gths of variable extem h ave heen suggested.Ho weve r, the findings o f a study by Pennington c t al ( 13 ) did no t support the concept of radical howe l resection .These oh-6.G rcen~1ein AJ, S;ichar DB, Pastemak BS, Janowicz HD.Reopenition and servers found no difference in recu rren ce rates wh ether there was d isease at t he rescctilm m argin.Lee ct a l ( 14) al~o re po rted that there was no ~1gnificant diffe rence in the ttmcs o r frequenc ies of recurrence a mo n g 24 patie nts with active inflammat ion ur Lo the limit of resection and a s imilar number studied with no disease at the resection ma rg in.The ir reCt)mmcndatio n was, therefore, to carry out 'cnteroplasty' witho ut resectio n o n r at1ents with multiple areas of d isease.They cla imed satisfacto ry results, wnh prese rvatio n ot as muc h bowe l as possihle using these Recurrence in Crohn's disease q ue nt occurrence of recurrent st rictures at origina l st ricturcplasty sites, occurnng in approx imately 2°1<, ( three of 127) of repo rted striLture plastics ( 17).
A ltho ugh Ritchie and Lockha rt-Mummery ( 18 ) re po rted an inc reased recurrence rate in patie nts with staged o perative procedures, this find mg is disputed hy S te inberg c t a l ( I 9) who found no suc h differen ce.
Cooke ct a l (20) found that the n umher of operatio ns was greate r in patien ts who received steroids.However, patien ts who have required and received steroid therapy arc not , in most respec ts, clinically comparable to those who have nor.
The ul t ima te o bi ecti ve of trea tme n t of Crohn's disease 1s a ph ys10-log1cally we ll pa tient, wh o is a ble to lead a norma l life, wo rk regularl y, a nd inte rac t 1,oc.ially in his o r her o rdina ry enviro nme n t. S tudies fro m Leeds, Birmingha m and New Yo rk, have fo und favora bl e results in ove r 90% of pa tie nts (2 l -23).
T he decisio n to intervene surgically in recurrent Crohn 's disease is o ne of the most cha lle nging problems in clinical medic ine.It sho uld be a jo int decis ion m ad e by surgeon and gastro-enternlog1st.When made at an appropnate time fo llowing fa ilure of medi cal thcrnpy to con trol the disease, ~urg ical intervention will lead to a be tter quality of li fe, reduce mo rbidity and minimize morrnl1ty 111 this ch ronic, inc urable intestinal affli ctio n.
Profe5sor of Surger:v, The Moun( Sinai School of Medicine of the City Unit•L>r.my of New York, New York, New York, USA Comis/>ondence and reprinL1: Dr N Green.1Cem,Muun( Smai Medical Center, Department of Surgery.One Gustat•e L Lev)• Place, Neu, York, NY /0029, USA CAN] GASTROENTERL)L VOL 7 No 2 FEBRUARY 1993 C ROI IN ET AL (I) IN T l IEIR INITIAL Pen nmgton L. l lamilwn SR, Bayless TM, Cameron JL.Surgical man.igemen1 of Crohn 's disease.I ntlucnce of disease at margin of resect ion.Ann Surg 1980;192: 31 1-8.14. Lee ECG, Papaioannou N.