Avoiding a stoma

Abstract

Total proctocolectomy and ileostomy for Crohn's colitis offers a low recurrence rate but commits patients to a permanent ileostomy. In contrast, segmental resection may predispose patients to recurrence and further surgery but may delay or avoid a stoma in select individuals. AIM: This study was undertaken to determine the risk of recurrence and the need for permanent stoma in patients treated with segmental or abdominal colectomy for Crohn's colitis. METHODS: Between 1976 and 1985, 699 patients underwent surgery for Crohn's colitis at the Mayo Clinic. Patients who had a total proctocolectomy and end ileostomy or primary ileal or anorectal disease were excluded from further study. Fifty-three patients had a colon resection without a permanent stoma, and 49 were alive and available for follow-up. During a mean follow-up of 14 years, completed questionnaires provided current details on subsequent medical and surgical therapies and/or stomas that were required. In these 49 patients, Crohn's of the colon involved the right, left, and both sides of the colon in 12, 31, and 6 patients, respectively, and involved less than one-third, one to two-thirds, and greater than two-thirds of the colon in 23, 25, and 1 patients, respectively. RESULTS: Twenty-two of fortynine patients (45 percent) required no further therapy. In 27 patients (55 percent), further treatment was required, including 11 (22 percent) patients who were managed medically (only 4>1 year) and 16 (33 percent) patients who were managed surgically. Three recurrences developed in the small bowel; the remaining 24 developed in the colon. For the 16 patients with recurrence requiring surgery, mean time to recurrence was 51±14 months; in all cases, recurrent disease involved the colon, with four anastomotic recurrences. At first recurrence, ten patients underwent another limited colon resection, and six patients underwent completion proctectomy with permanent ileostomy. Five patients required a third procedure, only one of which resulted in a permanent ileostomy. Therefore, 42 patients (86 percent) remained stoma-free, and 7 (14 percent) ultimately required permanent ileostomy, with a mean stoma-free interval of 23±4 months. CONCLUSION: Colon resection without proctectomy in select patients with limited colonic Crohn's disease can delay or avoid the necessity of a permanent stoma.