TY - JOUR
AU - Bemelman, W A
AB - Abstract Background Segmental colonic resection is commonly performed in patients with colorectal Crohn's disease. The aim of this study was to evaluate the outcome after segmental colonic resection and to define risk factors for re-resection. Methods Consecutive patients who had an initial segmental colonic resection for Crohn's colitis between 1987 and 2000 were evaluated. Patients who underwent ileocolonic resection were excluded. Patient-, disease- and treatment-related variables were assessed as possible risk factors for disease recurrence. Results Ninety-one patients (62 women) with a median follow-up of 8·3 years were studied. Thirty patients (33 per cent) had at least one re-resection, of whom 20 finally underwent total (procto)colectomy. Female sex and a history of perianal disease were identified as independent risk factors for re-resection: odds ratio 12·52 (95 per cent confidence interval (c.i.) 2·38 to 65·84) and 13·94 (95 per cent c.i. 3·02 to 64·27) respectively. Forty (44 per cent) of the 91 patients had a stoma at the end of the study period. Of the 30 patients who had re-resection, 24 finally had a stoma. Conclusion Segmental resection for Crohn's colitis is justified. Recurrence is more frequent in women and in those with a history of perianal disease. Introduction Between 70 and 90 per cent of patients with Crohn's disease require surgical intervention within their lifetime. The reoperation rate is approximately 40–50 per cent 10–15 years after the first operation1–3. There is agreement that limited segmental resection or strictureplasty of the diseased bowel should be carried out if the small intestine is affected because the extent of resection does not influence the recurrence rate4,5. However, the surgical treatment of patients with Crohn's colitis remains controversial. Although proctocolectomy with ileal pouch–anal anastomosis is performed for ulcerative colitis, this is relatively contraindicated in patients with colorectal Crohn's disease6 and segmental resection is the most commonly performed procedure. More extensive resections, such as total colectomy, are recommended by some surgeons because of the high risk of further resections or permanent stoma formation. A proportion of patients finally undergo total (procto)colectomy in two or more steps. In some patients an ileostomy is created during the first resection, with the intention of reanastomosing the ileum to the remaining part of the colon or rectum at a later date. However, restoration of bowel continuity is often not performed because the remaining colon or rectum is destroyed by disease or there is persisting distal disease activity7. It remains to be determined whether segmental resection of the affected part is the most appropriate operation, or whether more radical ‘prophylactic’ resection should be performed. Many investigators have tried to identify patient groups at high risk of recurrence that requires further surgery after resection for Crohn's disease. It has been suggested that there are different types of Crohn's disease, based on clinical presentation or site of disease. Some authors consider Crohn's colitis as a separate clinical entity8. Potential risk factors have also been studied. To date, only smoking has been identified as a significant risk factor for recurrence after operation2. The aim of this study was to evaluate the outcome of segmental resection for colorectal Crohn's disease and to analyse potential risk factors for surgical recurrence. The primary objective was to investigate whether segmental resection or a more extensive colonic resection such as total (procto)colectomy is the better procedure in such patients. Patients and methods Consecutive patients who underwent initial resection for colorectal Crohn's disease between January 1987 and July 2000 were evaluated retrospectively and followed until March 2004. Patients were identified from the database of the Department of Pathology. The diagnosis of Crohn's disease was based on accepted clinical, radiological and histological criteria9. Patients with indeterminate colitis, those who had resection for terminal ileitis with limited caecal involvement, and patients with incomplete follow-up were excluded. Patients who had their initial colorectal resection at another hospital or before the study period were also excluded. All resections of the colon and rectum, apart from proctocolectomy and ileocaecal resection, were considered as segmental colorectal resections. Left segmental resection was defined as a resection involving any part of the colon between the middle of the transverse colon and the colorectal junction, resection of the rectum itself, or a combination of these. Right segmental resection was defined as resection of any part of the colon between the ileocaecal junction and the mid-transverse colon. Subtotal colectomy was defined as resection of the colon between the ileocaecal junction and the transition of the descending colon to the sigmoid colon. Total colectomy was defined as resection of the entire colon between the ileocaecal and colorectal junctions. This centre employed a restrictive surgical policy for Crohn's colitis. Only the macroscopically affected part of the bowel was resected at the first operation and no prophylactic resections were performed. The rectum was preserved where possible. Re-resection was defined as a second resection of any part of the colon or rectum after the initial segmental colorectal resection. Reoperation with resection for preanastomotic small bowel recurrence was not defined as a colorectal re-resection. Surgical treatment without resection and limited resection of an existing (colo)stomy for technical reasons to restore bowel continuity were not considered as re-resections. To study risk factors for surgical recurrence, patients were divided into two groups: those who had a re-resection of the colon or rectum and those who did not. Variables analysed included sex, age, family history of Crohn's disease, body mass index (BMI), time between diagnosis and first resection, smoking habit, history of perianal disease, site of disease, indication for surgery, type of resection, time between first operation and reoperation, and complications. Differences between groups were tested using the χ2 test for categorical data, and Student's t test or Mann–Whitney U test for continuous data, depending on distribution. Univariate and multivariate logistic regression analysis was performed to identify independent risk factors for surgical recurrence. Kaplan–Meier curves and the log rank test were used to analyse reoperation-free survival. P < 0·050 was considered statistically significant for all tests. Statistical analysis was done using SPSS® version 11.5 (SPSS, Chicago, Illinois, USA). Results Between 1987 and 2000, 153 patients underwent resection for colorectal Crohn's disease. Sixty-two patients were excluded from the analysis (Fig. 1). The remaining 91 patients (62 women; 68 per cent), with a median age of 30·8 (interquartile range (i.q.r.) 27·1–45·0) years, underwent segmental resection for colorectal Crohn's disease. Patient characteristics are summarized in Table 1. The median duration of follow-up after primary segmental resection until the end of the study period was 8·3 (i.q.r. 5·2–10·9) years. Indications for surgery are shown in Table 2. Three patients underwent surgery for perforation, as a result of colonoscopy in two. For eight patients who died during the study interval, the date of death was defined as the end of the study period. Fig. 1 Open in new tabDownload slide Surgical procedures carried out in 91 patients with colorectal Crohn's disease. Numbers of stomas are those at the end of the study interval. *One patient refused a stoma and had an ileal pouch–anal anastomosis Table 1 Characteristics of 91 patients who underwent colorectal resection . All patients (n = 91) . Surgical recurrence (n = 30) . No surgical recurrence (n = 61) . P . Women 62 (68) 25 (83) 37 (60·1) 0·029† Family history 9 (11) 5 (17) 4 (8) 0·190† Smoker 40 (44) 13 (43) 27 (44) 0·933† History of perianal disease 47 (52) 23 (77) 24 (39) 0·001† Site of first resection  Left 42 (46) 18 (60) 24 (39) 0·063†  Right 26 (29) 4 (13) 22 (36)  Subtotal 23 (25) 8 (27) 15 (25) BMI at first resection (kg/m2)* 22·0 (19·7–23·9) 20·1 (18·7–23·8) 22·2 (20·0–24·9) 0·182‡ Low BMI (< 22·0 kg/m2) 35 (51) 14 (64) 21 (45) 0·142† Age at onset of disease (years)* 24·7 (19·2–36·1) 26·2 (20·2–35·1) 24·6 (17·8–41·7) 0·655‡ Age at onset ≥ 24·7 years 45 (51) 15 (52) 30 (50) 0·879† Age at first resection (years)* 30·8 (27·1–45·0) 32·9 (27·6–45·4) 30·1 (25·2–45·8) 0·856‡ Age at first resection ≥ 30·8 years 45 (49) 17 (57) 28 (46) 0·334† Duration of disease before operation (years)* 4·0 (1·9–9·7) 6·5 (2·0–11·7) 3·8 (1·7–8·7) 0·266‡ Duration of disease ≥ 4·0 years 45 (51) 17 (59) 28 (47) 0·290† . All patients (n = 91) . Surgical recurrence (n = 30) . No surgical recurrence (n = 61) . P . Women 62 (68) 25 (83) 37 (60·1) 0·029† Family history 9 (11) 5 (17) 4 (8) 0·190† Smoker 40 (44) 13 (43) 27 (44) 0·933† History of perianal disease 47 (52) 23 (77) 24 (39) 0·001† Site of first resection  Left 42 (46) 18 (60) 24 (39) 0·063†  Right 26 (29) 4 (13) 22 (36)  Subtotal 23 (25) 8 (27) 15 (25) BMI at first resection (kg/m2)* 22·0 (19·7–23·9) 20·1 (18·7–23·8) 22·2 (20·0–24·9) 0·182‡ Low BMI (< 22·0 kg/m2) 35 (51) 14 (64) 21 (45) 0·142† Age at onset of disease (years)* 24·7 (19·2–36·1) 26·2 (20·2–35·1) 24·6 (17·8–41·7) 0·655‡ Age at onset ≥ 24·7 years 45 (51) 15 (52) 30 (50) 0·879† Age at first resection (years)* 30·8 (27·1–45·0) 32·9 (27·6–45·4) 30·1 (25·2–45·8) 0·856‡ Age at first resection ≥ 30·8 years 45 (49) 17 (57) 28 (46) 0·334† Duration of disease before operation (years)* 4·0 (1·9–9·7) 6·5 (2·0–11·7) 3·8 (1·7–8·7) 0·266‡ Duration of disease ≥ 4·0 years 45 (51) 17 (59) 28 (47) 0·290† Values in parentheses are percentages unless indicated otherwise; * values are median (interquartile range). Data on family history, body mass index (BMI), age at onset of disease and duration of disease were missing for ten, 22, two and two patients respectively. † χ2 test; ‡ Student's t test. Open in new tab Table 1 Characteristics of 91 patients who underwent colorectal resection . All patients (n = 91) . Surgical recurrence (n = 30) . No surgical recurrence (n = 61) . P . Women 62 (68) 25 (83) 37 (60·1) 0·029† Family history 9 (11) 5 (17) 4 (8) 0·190† Smoker 40 (44) 13 (43) 27 (44) 0·933† History of perianal disease 47 (52) 23 (77) 24 (39) 0·001† Site of first resection  Left 42 (46) 18 (60) 24 (39) 0·063†  Right 26 (29) 4 (13) 22 (36)  Subtotal 23 (25) 8 (27) 15 (25) BMI at first resection (kg/m2)* 22·0 (19·7–23·9) 20·1 (18·7–23·8) 22·2 (20·0–24·9) 0·182‡ Low BMI (< 22·0 kg/m2) 35 (51) 14 (64) 21 (45) 0·142† Age at onset of disease (years)* 24·7 (19·2–36·1) 26·2 (20·2–35·1) 24·6 (17·8–41·7) 0·655‡ Age at onset ≥ 24·7 years 45 (51) 15 (52) 30 (50) 0·879† Age at first resection (years)* 30·8 (27·1–45·0) 32·9 (27·6–45·4) 30·1 (25·2–45·8) 0·856‡ Age at first resection ≥ 30·8 years 45 (49) 17 (57) 28 (46) 0·334† Duration of disease before operation (years)* 4·0 (1·9–9·7) 6·5 (2·0–11·7) 3·8 (1·7–8·7) 0·266‡ Duration of disease ≥ 4·0 years 45 (51) 17 (59) 28 (47) 0·290† . All patients (n = 91) . Surgical recurrence (n = 30) . No surgical recurrence (n = 61) . P . Women 62 (68) 25 (83) 37 (60·1) 0·029† Family history 9 (11) 5 (17) 4 (8) 0·190† Smoker 40 (44) 13 (43) 27 (44) 0·933† History of perianal disease 47 (52) 23 (77) 24 (39) 0·001† Site of first resection  Left 42 (46) 18 (60) 24 (39) 0·063†  Right 26 (29) 4 (13) 22 (36)  Subtotal 23 (25) 8 (27) 15 (25) BMI at first resection (kg/m2)* 22·0 (19·7–23·9) 20·1 (18·7–23·8) 22·2 (20·0–24·9) 0·182‡ Low BMI (< 22·0 kg/m2) 35 (51) 14 (64) 21 (45) 0·142† Age at onset of disease (years)* 24·7 (19·2–36·1) 26·2 (20·2–35·1) 24·6 (17·8–41·7) 0·655‡ Age at onset ≥ 24·7 years 45 (51) 15 (52) 30 (50) 0·879† Age at first resection (years)* 30·8 (27·1–45·0) 32·9 (27·6–45·4) 30·1 (25·2–45·8) 0·856‡ Age at first resection ≥ 30·8 years 45 (49) 17 (57) 28 (46) 0·334† Duration of disease before operation (years)* 4·0 (1·9–9·7) 6·5 (2·0–11·7) 3·8 (1·7–8·7) 0·266‡ Duration of disease ≥ 4·0 years 45 (51) 17 (59) 28 (47) 0·290† Values in parentheses are percentages unless indicated otherwise; * values are median (interquartile range). Data on family history, body mass index (BMI), age at onset of disease and duration of disease were missing for ten, 22, two and two patients respectively. † χ2 test; ‡ Student's t test. Open in new tab Table 2 Indications for primary segmental resection in 91 patients with colorectal Crohn's disease . No. of patients . Failure of medical treatment 11 Colonic stenosis or stricture 45 Fistula 17 Emergency surgery  7  Intra-abdominal abscess  2  Toxic megacolon  1  Colonic perforation with peritonitis  3  Ileus  1 Malignancy  1 Other 10 . No. of patients . Failure of medical treatment 11 Colonic stenosis or stricture 45 Fistula 17 Emergency surgery  7  Intra-abdominal abscess  2  Toxic megacolon  1  Colonic perforation with peritonitis  3  Ileus  1 Malignancy  1 Other 10 Open in new tab Table 2 Indications for primary segmental resection in 91 patients with colorectal Crohn's disease . No. of patients . Failure of medical treatment 11 Colonic stenosis or stricture 45 Fistula 17 Emergency surgery  7  Intra-abdominal abscess  2  Toxic megacolon  1  Colonic perforation with peritonitis  3  Ileus  1 Malignancy  1 Other 10 . No. of patients . Failure of medical treatment 11 Colonic stenosis or stricture 45 Fistula 17 Emergency surgery  7  Intra-abdominal abscess  2  Toxic megacolon  1  Colonic perforation with peritonitis  3  Ileus  1 Malignancy  1 Other 10 Open in new tab Postoperative surgical recurrence Thirty (33 per cent) of the 91 patients had one or more re-resections. Twenty of these 30 patients finally underwent total (procto)colectomy (Fig. 1). Of the 20 patients who had (procto)colectomy, 17 had a history of perianal disease and three did not (P = 0·001). The median interval between the first segmental resection and re-resection was 22·0 (i.q.r. 14·0–49·3) months. Of the 26 patients who had initial right-sided segmental resection, one finally underwent total (procto)colectomy, compared with 12 of 42 patients who initially underwent left-sided segmental resection and seven of 23 patients whose first operation was subtotal colectomy. Forty (44 per cent) of the 91 patients had a stoma at the end of the study period, seven after initial right colectomy, 23 after left colectomy and ten after subtotal colectomy. Among the 30 patients who had re-resection, three of four patients who had right segmental resection initially had a stoma at the end of the study period, compared with 15 of 18 patients who had initial left segmental resection and six of eight patients who first underwent subtotal resection. Of the 61 patients who did not undergo reoperation, 16 (26 per cent) had a stoma at the end of the study period. In 13 of these patients the stoma was originally deemed to be temporary during initial resection (in three patients the temporary stoma was present at the time of death). In the remaining three patients the stoma was created after the initial resection. Thirty-one of the 47 patients with a history of perianal disease finally had a stoma, compared with nine of the 44 patients with no history of perianal disease: odds ratio 7·54 (95 per cent confidence interval 2·92 to 19·46). Risk factors Results of analysis of potential risk factors for re-resection are summarized in Table 3. In univariate regression analysis, a history of perianal disease, left (compared with right) segmental resection and female sex were associated with a higher rate of colorectal re-resection. Multivariate regression analysis identified history of perianal disease and female sex as independent risk factors for re-resection (Table 3). Table 3 Logistic regression analysis of factors associated with colorectal surgical recurrence in 91 patients who underwent primary segmental colorectal resection . Univariate odds ratio . Multivariate odds ratio . Female sex 3·24 (1·09, 9·64) 12·52 (2·38, 65·84) Family history of Crohn's disease 2·50 (0·62, 10·17) — Smoking 0·93 (0·40, 2·33) 0·30 (0·07, 1·26) History of perianal disease 5·07 (1·88, 13·63) 13·94 (3·02, 64·27) Site of first resection  Right 1·00  Left 4·13 (1·21, 14·09) —  Subtotal 2·93 (0·75, 11·52) — Low BMI at first resection (< 22·0 kg/m2) 2·17 (0·76, 6·14) 1·78 (0·51, 6·20) Older age at onset of disease (≥ 24·7 years) 1·07 (0·44, 2·60) Older age at first resection (≥ 30·8 years) 1·54 (0·64, 3·72) — Longer duration of disease before operation (≥ 4·0 years) 1·62 (0·66, 3·97) — . Univariate odds ratio . Multivariate odds ratio . Female sex 3·24 (1·09, 9·64) 12·52 (2·38, 65·84) Family history of Crohn's disease 2·50 (0·62, 10·17) — Smoking 0·93 (0·40, 2·33) 0·30 (0·07, 1·26) History of perianal disease 5·07 (1·88, 13·63) 13·94 (3·02, 64·27) Site of first resection  Right 1·00  Left 4·13 (1·21, 14·09) —  Subtotal 2·93 (0·75, 11·52) — Low BMI at first resection (< 22·0 kg/m2) 2·17 (0·76, 6·14) 1·78 (0·51, 6·20) Older age at onset of disease (≥ 24·7 years) 1·07 (0·44, 2·60) Older age at first resection (≥ 30·8 years) 1·54 (0·64, 3·72) — Longer duration of disease before operation (≥ 4·0 years) 1·62 (0·66, 3·97) — Values in parentheses are 95 per cent confidence intervals. All variables in Table 1 were included in logistic regression model. Only female sex, smoking, history of perianal disease and low body mass index (BMI) at first resection were entered in the multivariate logistic regression model. Site of first resection (left versus right) was not entered in this model because of the statistically significant correlation between perianal disease and left-sided resections (P < 0·050). Open in new tab Table 3 Logistic regression analysis of factors associated with colorectal surgical recurrence in 91 patients who underwent primary segmental colorectal resection . Univariate odds ratio . Multivariate odds ratio . Female sex 3·24 (1·09, 9·64) 12·52 (2·38, 65·84) Family history of Crohn's disease 2·50 (0·62, 10·17) — Smoking 0·93 (0·40, 2·33) 0·30 (0·07, 1·26) History of perianal disease 5·07 (1·88, 13·63) 13·94 (3·02, 64·27) Site of first resection  Right 1·00  Left 4·13 (1·21, 14·09) —  Subtotal 2·93 (0·75, 11·52) — Low BMI at first resection (< 22·0 kg/m2) 2·17 (0·76, 6·14) 1·78 (0·51, 6·20) Older age at onset of disease (≥ 24·7 years) 1·07 (0·44, 2·60) Older age at first resection (≥ 30·8 years) 1·54 (0·64, 3·72) — Longer duration of disease before operation (≥ 4·0 years) 1·62 (0·66, 3·97) — . Univariate odds ratio . Multivariate odds ratio . Female sex 3·24 (1·09, 9·64) 12·52 (2·38, 65·84) Family history of Crohn's disease 2·50 (0·62, 10·17) — Smoking 0·93 (0·40, 2·33) 0·30 (0·07, 1·26) History of perianal disease 5·07 (1·88, 13·63) 13·94 (3·02, 64·27) Site of first resection  Right 1·00  Left 4·13 (1·21, 14·09) —  Subtotal 2·93 (0·75, 11·52) — Low BMI at first resection (< 22·0 kg/m2) 2·17 (0·76, 6·14) 1·78 (0·51, 6·20) Older age at onset of disease (≥ 24·7 years) 1·07 (0·44, 2·60) Older age at first resection (≥ 30·8 years) 1·54 (0·64, 3·72) — Longer duration of disease before operation (≥ 4·0 years) 1·62 (0·66, 3·97) — Values in parentheses are 95 per cent confidence intervals. All variables in Table 1 were included in logistic regression model. Only female sex, smoking, history of perianal disease and low body mass index (BMI) at first resection were entered in the multivariate logistic regression model. Site of first resection (left versus right) was not entered in this model because of the statistically significant correlation between perianal disease and left-sided resections (P < 0·050). Open in new tab Among the 30 patients who underwent re-resection, the interval between the initial surgery and reoperation was longer for smokers than for non-smokers (median 3·2 (i.q.r. 1·5–4·7) versus 1·5 (i.q.r. 0·8–2·8) years respectively; P = 0·052) (Table 4). Other risk factors examined had no significant influence on the interval between primary surgery and reoperation (Table 4). Table 4 Evaluation of variables influencing interval between initial resection and reoperation in 30 patients who had reoperation . Time between first segmental resection and re-resection (years) . P* . . Mean(s.d.) . Median . 95% c.i. . Sex 0·978  F 3·1(3·4) 2·0 1·7, 4·6  M 2·9(2·3) 1·3 0·0, 5·7 Family history 0·773  Yes 4·3(6·3) 2·7 −3·5, 12·1  No 2·9(2·4) 1·8 1·9, 3·9 Smoker 0·052  Yes 3·6(2·5) 3·2 2·1, 5·1  No 2·7(3·7) 1·5 0·8, 4·6 History of perianal disease 0·713  Yes 2·7(2·3) 2·0 1·7, 3·7  No 4·3(5·3) 1·6 −0·6, 9·2 Site of first resection  Right 6·2(6·9) 4·7 −4·8, 17·2  Left 2·8(2·4) 2·6 1·7, 4·0 0·496†  Subtotal 2·2(1·6) 1·7 0·8, 3·5 0·610† BMI at first resection (kg/m2) 0·891  ≥ 22·0 2·9(2·5) 2·6 0·8, 5·0  < 22·0 3·4(4·1) 1·8 1·0, 5·7 Age at onset of disease (years) 0·694  ≥ 24·7 2·6(2·3) 1·8 1·4, 4·1  < 24·7 3·6(4·0) 2·2 1·3, 6·0 Age at first resection (years) 0·075  ≥ 30·8 3·3(2·2) 3·1 2·2, 4·4  < 30·8 2·9(4·3) 1·3 0·3, 5·5 Duration of disease before operation (years) 0·894  ≥ 4·0 2·7(2·1) 1·7 1·6, 3·8  < 4·0 3·9(4·4) 2·2 1·0, 6·7 . Time between first segmental resection and re-resection (years) . P* . . Mean(s.d.) . Median . 95% c.i. . Sex 0·978  F 3·1(3·4) 2·0 1·7, 4·6  M 2·9(2·3) 1·3 0·0, 5·7 Family history 0·773  Yes 4·3(6·3) 2·7 −3·5, 12·1  No 2·9(2·4) 1·8 1·9, 3·9 Smoker 0·052  Yes 3·6(2·5) 3·2 2·1, 5·1  No 2·7(3·7) 1·5 0·8, 4·6 History of perianal disease 0·713  Yes 2·7(2·3) 2·0 1·7, 3·7  No 4·3(5·3) 1·6 −0·6, 9·2 Site of first resection  Right 6·2(6·9) 4·7 −4·8, 17·2  Left 2·8(2·4) 2·6 1·7, 4·0 0·496†  Subtotal 2·2(1·6) 1·7 0·8, 3·5 0·610† BMI at first resection (kg/m2) 0·891  ≥ 22·0 2·9(2·5) 2·6 0·8, 5·0  < 22·0 3·4(4·1) 1·8 1·0, 5·7 Age at onset of disease (years) 0·694  ≥ 24·7 2·6(2·3) 1·8 1·4, 4·1  < 24·7 3·6(4·0) 2·2 1·3, 6·0 Age at first resection (years) 0·075  ≥ 30·8 3·3(2·2) 3·1 2·2, 4·4  < 30·8 2·9(4·3) 1·3 0·3, 5·5 Duration of disease before operation (years) 0·894  ≥ 4·0 2·7(2·1) 1·7 1·6, 3·8  < 4·0 3·9(4·4) 2·2 1·0, 6·7 BMI, body mass index; c.i., confidence interval. * Mann–Whitney U test; † versus right. Open in new tab Table 4 Evaluation of variables influencing interval between initial resection and reoperation in 30 patients who had reoperation . Time between first segmental resection and re-resection (years) . P* . . Mean(s.d.) . Median . 95% c.i. . Sex 0·978  F 3·1(3·4) 2·0 1·7, 4·6  M 2·9(2·3) 1·3 0·0, 5·7 Family history 0·773  Yes 4·3(6·3) 2·7 −3·5, 12·1  No 2·9(2·4) 1·8 1·9, 3·9 Smoker 0·052  Yes 3·6(2·5) 3·2 2·1, 5·1  No 2·7(3·7) 1·5 0·8, 4·6 History of perianal disease 0·713  Yes 2·7(2·3) 2·0 1·7, 3·7  No 4·3(5·3) 1·6 −0·6, 9·2 Site of first resection  Right 6·2(6·9) 4·7 −4·8, 17·2  Left 2·8(2·4) 2·6 1·7, 4·0 0·496†  Subtotal 2·2(1·6) 1·7 0·8, 3·5 0·610† BMI at first resection (kg/m2) 0·891  ≥ 22·0 2·9(2·5) 2·6 0·8, 5·0  < 22·0 3·4(4·1) 1·8 1·0, 5·7 Age at onset of disease (years) 0·694  ≥ 24·7 2·6(2·3) 1·8 1·4, 4·1  < 24·7 3·6(4·0) 2·2 1·3, 6·0 Age at first resection (years) 0·075  ≥ 30·8 3·3(2·2) 3·1 2·2, 4·4  < 30·8 2·9(4·3) 1·3 0·3, 5·5 Duration of disease before operation (years) 0·894  ≥ 4·0 2·7(2·1) 1·7 1·6, 3·8  < 4·0 3·9(4·4) 2·2 1·0, 6·7 . Time between first segmental resection and re-resection (years) . P* . . Mean(s.d.) . Median . 95% c.i. . Sex 0·978  F 3·1(3·4) 2·0 1·7, 4·6  M 2·9(2·3) 1·3 0·0, 5·7 Family history 0·773  Yes 4·3(6·3) 2·7 −3·5, 12·1  No 2·9(2·4) 1·8 1·9, 3·9 Smoker 0·052  Yes 3·6(2·5) 3·2 2·1, 5·1  No 2·7(3·7) 1·5 0·8, 4·6 History of perianal disease 0·713  Yes 2·7(2·3) 2·0 1·7, 3·7  No 4·3(5·3) 1·6 −0·6, 9·2 Site of first resection  Right 6·2(6·9) 4·7 −4·8, 17·2  Left 2·8(2·4) 2·6 1·7, 4·0 0·496†  Subtotal 2·2(1·6) 1·7 0·8, 3·5 0·610† BMI at first resection (kg/m2) 0·891  ≥ 22·0 2·9(2·5) 2·6 0·8, 5·0  < 22·0 3·4(4·1) 1·8 1·0, 5·7 Age at onset of disease (years) 0·694  ≥ 24·7 2·6(2·3) 1·8 1·4, 4·1  < 24·7 3·6(4·0) 2·2 1·3, 6·0 Age at first resection (years) 0·075  ≥ 30·8 3·3(2·2) 3·1 2·2, 4·4  < 30·8 2·9(4·3) 1·3 0·3, 5·5 Duration of disease before operation (years) 0·894  ≥ 4·0 2·7(2·1) 1·7 1·6, 3·8  < 4·0 3·9(4·4) 2·2 1·0, 6·7 BMI, body mass index; c.i., confidence interval. * Mann–Whitney U test; † versus right. Open in new tab Re-resection-free survival curves for the 91 patients grouped with respect to the site of initial resection, smoking habit, sex and history of perianal disease are shown in Figs 2–5 respectively. Sex (P = 0·018), site of initial resection (P = 0·009) and a history of perianal disease (P = 0·002) significantly affected re-resection-free survival. Fig. 2 Open in new tabDownload slide Reoperation-free survival curves for 91 patients grouped according to site of disease. P = 0·009 (log rank test) Fig. 3 Open in new tabDownload slide Reoperation-free survival curves for 91 patients grouped according to smoking habit Fig. 4 Open in new tabDownload slide Reoperation-free survival curves for 91 patients grouped according to sex. P = 0·018 (log rank test) Fig. 5 Open in new tabDownload slide Reoperation-free survival curves for 91 patients grouped according to history of perianal disease. P = 0·002 (log rank test) Discussion Surgical recurrence rates ranging from 24 to 62 per cent have been reported after segmental resection for Crohn's colitis10–13. This variation in re-resection rates can be explained by differences in length of follow-up, inclusion criteria and definitions of re-resection between series. In most previous studies, no differentiation was made with respect to the site of primary colonic resection (left, right or subtotal colectomy). Strict inclusion criteria and definitions were applied in the present study in order to obtain a clear insight into re-resection-free survival and stoma rates, subdivided according to the primary site of colonic resection. Only reoperation involving (segmental) resection of the colon or rectum was defined as a re-resection. The present findings cannot therefore be compared with those of studies in which surgical recurrence was defined as any operation after initial segmental resection, including reoperation for diverting stoma or small bowel stenosis. The median follow-up in the present study was 8·3 years. The number of patients who require further resection might be expected to increase with longer follow-up. If patients who had been operated on previously in another hospital had been included, as in most other studies, the re-resection rate might have been higher as patients referred to tertiary centres are more likely to require re-resection. Two-thirds of the patients with a history of perianal disease in the present series eventually had a stoma compared with 20 per cent with no such history. These rates are in agreement with those of Hurst et al.14, who found that 67 per cent of patients who required operation for perianal Crohn's disease eventually had a permanent stoma if Crohn's disease was present in the rectal mucosa. In another study, more than half of the patients suffering from perianal Crohn's disease finally required a stoma15. Both surgical recurrence and stoma rates were low after initial right-sided resection, whereas higher rates were noted after left-sided and subtotal resection. When interpreting these results, it must be appreciated that resection for preanastomotic recurrence in the small bowel was not considered as a colorectal re-resection. A history of perianal disease and female sex were identified as significant risk factors for re-resection both in univariate and in multivariate analysis. Some other studies have also found that the resection rate is higher among women16,17, but most found no difference between the sexes18. None of the other factors evaluated was associated with a higher re-resection rate in regression analysis. The interval between initial segmental resection and re-resection was longer for smokers than for non-smokers, suggesting that smoking might have a protective effect on the length of surgical remission. Within the first 4 years after initial resection, smokers tended to have a longer re-resection-free survival, but this advantage was lost after 5 years and smoking had no significant overall influence. A review of the literature has revealed that smoking is the only risk factor for recurrence after operation2, in contrast to the present findings. This discrepancy might have arisen because only colorectal Crohn's disease and re-resection were analysed in the present study. Furthermore, this study included a relatively small number of patients and the results should therefore be interpreted with caution. Segmental resection for Crohn's colitis is justified because only one-third of patients have a surgical recurrence. However, the recurrence rate is significantly higher in women and those with a history of perianal disease. Furthermore, left-sided and subtotal resections are associated with higher surgical recurrence and stoma rates than right-sided procedures. Patients in these higher-risk groups must be informed about the chances of eventual (procto)colectomy and a permanent stoma if resection for recurrence becomes necessary. References 1 Bernell O , Lapidus A, Hellers G. Risk factors for surgery and recurrence in 907 patients with primary ileocaecal Crohn's disease . Br J Surg 2000 ; 87 : 1697 – 1701 . Google Scholar OpenURL Placeholder Text WorldCat 2 Borley NR , Mortensen NJ, Jewell DP. Preventing postoperative recurrence of Crohn's disease . Br J Surg 1997 ; 84 : 1493 – 1502 . Google Scholar OpenURL Placeholder Text WorldCat 3 Whelan G , Farmer RG, Fazio VW, Goormastic M. 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Google Scholar OpenURL Placeholder Text WorldCat 16 Kyle J . Prognosis after ileal resection for Crohn's disease . Br J Surg 1971 ; 58 : 735 – 737 . Google Scholar OpenURL Placeholder Text WorldCat 17 Lennard-Jones JE , Stalder GA. Prognosis after resection of chronic regional ileitis . Gut 1967 ; 8 : 332 – 336 . Google Scholar OpenURL Placeholder Text WorldCat 18 Williams JG , Wong WD, Rothenberger DA, Goldberg SM. Recurrence of Crohn's disease after resection . Br J Surg 1991 ; 78 : 10 – 19 . Google Scholar OpenURL Placeholder Text WorldCat Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
TI - Recurrence after segmental resection for colonic Crohn's disease
JF - British Journal of Surgery
DO - 10.1002/bjs.5050
DA - 2005-08-17
UR - https://www.deepdyve.com/lp/oxford-university-press/recurrence-after-segmental-resection-for-colonic-crohn-s-disease-2sbb09aatb
SP - 1143
EP - 1149
VL - 92
IS - 9
DP - DeepDyve
ER -