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Clinical Factors Contributing to Rapid Reoperation for Crohn’s Disease Patients Undergoing Resection and/or Strictureplasty

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Although surgically induced remission of Crohn’s disease following segmental resection/strictureplasty is effective and durable, a subpopulation of patients will require rapid reoperation. We reviewed our inflammatory bowel disease center’s database to identify patients who underwent multiple laparotomies. A retrospective analysis of consecutive Crohn’s disease patients (1998–2004) was performed, and patients requiring repeat laparotomy were identified. Rapid reoperation was defined as repeat intestinal surgery within 2 years. Demographic data and medical treatment were recorded. Clinical factors contributing to rapid reoperation were defined as (1) symptomatic adhesion, (2) residual strictures/technical error, (3) lack of effective medical therapy, and (4) severe disease despite medical treatment. Of 432 patients, 65 required two or more abdominal explorations, with 32 patients requiring rapid reoperation (50 surgeries). Residual strictures and technical error accounted for 20% of procedures; ineffective medical therapy was identified in 64%, whereas severe disease despite medical therapy was a contributing factor in 14%. Adhesions were found in a single patient. Kaplan–Meier analysis confirmed that rapid reoperation patients had significant and consistently shorter intervals between surgical procedures (i.e., interval between procedures 1 and 2 and 2 and 3). Residual strictures manifest during postop year 1, whereas recurrence of severe disease was the dominant contributing factor during year 2. Our data suggest that operative strategies emphasizing occult stricture detection and adequate medical therapy in Crohn’s disease patients may improve outcome and decrease the need for rapid re-exploration.

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Author information

Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, Department of Medicine, Digestive Disease Center, Froedtert Hospital, Milwaukee VA Medical Center, Medical College of Wisconsin, Milwaukee, WI, USA

    David G. Binion, Kenneth R. Theriot & Ossama Hatoum

  2. Department of Pathology, Digestive Disease Center, Froedtert Hospital, Milwaukee VA Medical Center, Medical College of Wisconsin, Milwaukee, WI, USA

    Sushrut Shidham

  3. Department of Surgery, Digestive Disease Center, Froedtert Hospital, Milwaukee VA Medical Center, Medical College of Wisconsin, 9200 West Wisconsin Ave, Milwaukee, WI, 53226, USA

    Sarah Lundeen & Mary F. Otterson

  4. Division of Biostatistics, Digestive Disease Center, Froedtert Hospital, Milwaukee VA Medical Center, Medical College of Wisconsin, Milwaukee, WI, USA

    Hyun J. Lim

Authors
  1. David G. Binion
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  2. Kenneth R. Theriot
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  3. Sushrut Shidham
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  4. Sarah Lundeen
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  5. Ossama Hatoum
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  6. Hyun J. Lim
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  7. Mary F. Otterson
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Correspondence to Mary F. Otterson.

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Discussion

694. Rapid Re-Operation for Crohn's Disease. Paper presented by Mary Otterson, M.D., Milwaukee, WI. E-mail: otterson@mcw.edu

Discussion by Susan Gearhart, M.D., Maryland. E-mail: sdemess1@jhmi.edu.

Dr. S. Gearhart (Baltimore, MD): I want to thank the authors, first of all, for the opportunity to discuss this paper and for their timely submission. I also want to congratulate you on an interesting and important study examining the clinical risk factors associated with reoperation for Crohn’s disease. I have questions on several specific aspects of your study.

First, the aim of your study was to identify clinical factors that are associated with the rapid reoperation for Crohn’s disease. Yet the clinical data with regards to the initial surgery type as it directly related to the need for rapid reoperation, for example, strictureplasty or no strictureplasty, laparoscopic, which you touch on in your manuscript, emergent or elective, is missing. Could you please elaborate on that? It also would be important to list factors which may affect healing in Crohn's disease, such as nutritional status of the patient or steroid use. Furthermore, in your mention in the manuscript about patients with colonic disease you decided to exclude them, and I didn't understand why you did, and then you did actually mention them when you described demographic data. Could you just touch on whether or not you were discussing colonic disease?

Second, you defined one of your clinical factors contributing to rapid reoperation for Crohn’s disease as inadequate immunomodulator therapy. I agree with you that there is certainly data to support the use of immunomodulator therapy in active Crohn’s disease and preventing clinical recurrence of the disease. However, the data is not compelling in the support of the use of immunomodulators in the prevention of surgical recurrence and the need to go back to the operating room for surgery for Crohn’s disease. And could you comment on your data with respect to randomized clinical trials and the use of immunomodulator therapy on the prevention of recurrence of Crohn’s disease postoperatively?

Finally, in your conclusions you suggest that this study supports the use of immunomodulators in patients who require rapid reoperation for Crohn's disease. This study is retrospective and lacks a control group and therefore this claim may be a bit premature. Do you have plans to look at this in a more prospective fashion?

Thank you.

Dr. Otterson: Thank you very much for your comments. I hope I remember all the questions in the appropriate order.

Regarding strictureplasty versus resection, we have looked at strictureplasty versus resection with recurrence and not seen any issues in the past. I think that the majority of the outside procedures are performed as resections and a very small minority are done as strictureplasties. At our institution most of our procedures are actually a combination of both strictureplasty and resection. So it is going to be difficult for us to give a conclusive result on that.

We do routinely pull a Foley catheter and inflate it to 2 cm through our intestine looking for missed strictures. In a paper that we wrote several years ago, we found that radiology underestimated a third of the strictures in a third of the patients. So if you have single strictures in first-time resections, the data is pretty good for radiology, but after that, if they have multiple resections or if they have had multiple strictures identified, you really need to look for additional strictures.

The nutritional factors, I don’t have data on that. We have looked in the past, and we did not see a difference with albumins down to a level of 3. The VAH study suggests that 2.5 is the magic number. We didn’t see any difference at a level of 2.5 for complications, postoperative intra-abdominal septic complications, but we did not specifically look at that with this.

Steroid use, most of the patients who came in with partial obstructive issues were on steroids to try to control their obstructive symptoms, but the majority of our patients, 80%, are on immunomodulator therapy before they come to the operating room. The patients who are not on drug therapy are those patients who are multiply drug intolerant, leading to novel concoctions of drugs, or who are noncompliant.

As far as randomized clinical trials, methotrexate, azathioprine, or 6-MP have all been shown in randomized prospective trials to be the only drugs that are capable of inducing prolonged remission with Crohn’s disease. The ACCENT II trials with infliximab and REMICADE are also supporting the data that good medical care prior to the surgical procedures are the way to go as far as maintaining disease-free intervals.

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Binion, D.G., Theriot, K.R., Shidham, S. et al. Clinical Factors Contributing to Rapid Reoperation for Crohn’s Disease Patients Undergoing Resection and/or Strictureplasty. J Gastrointest Surg 11, 1692–1698 (2007). https://doi.org/10.1007/s11605-007-0298-5

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