POSTOPERATIVE RECURRENCE OF CROHN'S DISEASE IN CHILDREN

Abstract

Background: Postoperative recurrence of Crohn's disease (CD) is well characterized in adults with symptomatic recurrence rates of 10% at 1 yr, 30% at 3 yrs and 40-50% at 5 yrs. To date, only one retrospective study has critically analyzed postoperative recurrence of CD in children. Methods: A retrospective analysis of patients with CD seen at CHOP from 1978-1996 who underwent resective surgery before 21 yrs of age was performed. Postoperative recurrence was defined as 1) CD-related symptoms with radiologic or endoscopic evidence of recurrence, or 2) an increase in Pediatric Crohn's Disease Activity Index (PCDAI) of >30 points with response to subsequent escalation in medical therapy. Recurrence rates were calculated using actuarial (Kaplan-Meier) log-rank analysis and correlated to specific historical, surgical and pathological factors. Results: Out of 339 pts with CD, 79 (23%) pts had resective surgeries. Records were available for 67 (85%) surgeries. 8 (12%) had colonic disease, 4 (6%) small bowel (SB) disease, 39 (58%) had ileocecal disease, and 16 (24%) had disease diffusely involving both the SB and colon. Average followup was 3.6 yr (med: 2.8 yr, range: 0-16.5 yr). Recurrence rate was 17% at 1yr, 38% at 3yrs, and 60% at 5 yrs. By univariate analysis, lymphopenia at surgery (p=0.05), or preoperative use of 6-mercaptopurine (6-MP) (p=0.004) or metronidazole (p=0.04) was associated with shorter recurrence free intervals (RFI) following surgery. Recurrence rate did not correlate with preoperative duration of CD or perforating indication for surgery. Patients with disease limited to the colon had a high rate of recurrence (Median RFI=1.16 yr), while those who had ileocecal disease had a low rate of recurrence (median RFI=4.36 yr), and those with diffuse disease (involving both the colon and SB) had an intermediate rate (median RFI=2.95 yr) (p=0.01). Multivariate analysis revealed that the use of 6-MP (p=0.0005) and a high PCDAI at the time of surgery (p=0.01) were independently associated with increased postoperative recurrence rates. Conclusions:Children with CD have a higher postoperative symptomatic recurrence rate than previously described in the adult literature. Children with colonic disease are at high risk for recurrence, those with diffuse disease are at intermediate risk, and those with ileocecal disease are at low risk for recurrence. Preoperative use of 6-MP and high PCDAI at surgery are independent predictors of early recurrence.