The long-term results of excisional surgery for primary and recurrent Crohn's disease of the large intestine

Abstract

Two-hundred and seven survivors of excisional surgery for primary Crohn's disease of the large intestine have been followed for a mean period of 15 years (range, 7 to 25 years). Of the 45 patients who were treated by colectomy and ileorectal anastomosis, 32 (71 percent) developed recurrence in the terminal ileum, rectum, or ileum and rectum, (and in the duodenum in one). Most recurrences appeared during the first few years, but there appeared to be some continuing predisposition to recurrence indefinitely. Nineteen of the patients with recurrences proceeded to rectal excision and ileostomy. A total of 17 patients (3 percent) with or without recurrence had good functional results with a retained ileorectal anastomosis. Of the 162 patients who were treated by ileostomy and colectomy or proctocolectomy (rarely rectal excision and iliac colostomy), 24 (14.8 percent) had recurrences, usually in the bowel immediately above the stoma and, occasionally, more extensively else-where. Most recurrences manifested themselves in the first eight to ten years after operation, and the continuing predisposition thereafter was relatively slight. The inconvenience occasioned by the stoma in these 162 patients was rated as nil in 36.4 percent, negligible in 33.3 percent, moderate or severe in 25.3 percent, and ileostomy refashioning was performed in 5.0 percent with improvement in most instances. The overall condition of the 162 patients was considered to be excellent in 71 percent, fair in 22.8 percent, and poor in 6.2 percent. Most of those placed in the second two categories were so graded because of intercurrent conditions which, if discounted, would have resulted in the general condition of 89 percent of patients being rated as excellent. In 141 patients who finished with a complete proctocolectomy, healing of the perineal wound was straightforward and complete in 61.7 percent, delayed but eventually complete in 28.4 percent, and perineal sinuses formed in 9.9 percent, but many of these healed after further operations. Forty-one of 207 patients treated for primary disease came to reoperation by ileectomy and ilcostomy for recurrent disease. At this writing, only four of the 40 patients followed for a mean period of over 12 years (range, one to 25 years) have developed further recurrences, but yet a third recurrence has appeared in two of those four. Gallstones developed in 5.3 percent and urinary stones in 2.4 percent of the 207 patients studied. The long-term prognosis as regards recurrence after colectomy and ileorectal anastomosis must be rated as mediocre, but the prognosis after ileostomy and colectomy or proctocolectomy seems to be more favorable than was often previously believed.