Previous Intestinal Resection Research Articles

Plastias de estenoses de intestino delgado na doença de Crohn: resultados imediatos e tardios

Strictureplasty is an alternative surgical procedure for Crohn's disease, particulary in patients with previous resections or many intestinal stenosis. To analyze surgical complications and clinical follow-up in patients submitted to strictureplasty secondary to Crohn's disease. Twenty-eight patients (57.1% male, mean age 33.3 years, range 16-54 years) with Crohn's disease and intestinal stenosis (small bowel, ileocecal region and ileocolic anastomosis) were submitted to strictureplasty, at one institution, between September 1991 and May 2004. Thirteen patients had previous intestinal resections. The mean follow-up was 58.1 months. A total of 116 strictureplasties were done (94 Heineke-Mikulicz--81%, 15 Finney--13%, seven side-to-side ileocolic strictureplasty--6%). Three patients were submitted to strictureplasty at two different surgical procedures and two in three procedures. Regarding to strictureplasty, postoperative complication rate was 25% and mortality was 3.6%. Early local complication rate was 57.1%, with three suture leaks (10.7%) and late complication was present in two patients, both with incisional hernial and enterocutaneous fistulas (28.6%). Patients remained hospitalized during a medium time of 12.4 days. Clinical and surgical recurrence rates were 63% and 41%, respectively. Among the patients submitted to another surgery, two patients had two more operations and one had three. Recurrence rate at strictureplasty site was observed in 3.5%, being Finney technique the commonest one. Presently, 19 patients had been asymptomatic with the majority of them under medical therapy. Strictureplasties have low complication rates, in spite of having been done at compromised site, with long term pain relief. Considering the clinical course of Crohn's disease, with many patients being submitted to intestinal resections, strictureplasties should be considered as an effective surgical treatment to spare long intestinal resections.

Assessment of endoscopic activity index and biological inflammatory markers in clinically active Crohnʼs disease with normal C-reactive protein serum level

Patients with clinically active Crohn's disease (CD), defined by a Crohn's Disease Activity Index (CDAI)>150, may have normal C-reactive protein (CRP) serum levels. In such cases, it is difficult to know whether these patients have really active disease or rather functional symptoms. This distinction is important to decide the most appropriate treatment. The aim of our work was to assess intestinal and colonic lesions in such patients and to look for biological markers potentially associated with endoscopic activity of the disease. We included 28 consecutive CD patients with CDAI>150 and a normal CRP level. These patients underwent a full colonoscopy with Crohn's Disease Endoscopy Index of Severity (CDEIS) calculation, fecal calprotectin, blood fibrinogen, acid alpha-1 glycoprotein, and erythrocyte sedimentation rate measurement. The Harvey-Bradshaw score was also calculated. Serum IL1 beta, IL6, IL8, sIL2R, and sTNFR2 were measured. The median CDAI was 181 (151-485). Almost all (92.9%) these patients had endoscopic lesions, but the majority had only mild lesions (CDEIS<or=6). No correlation was found between CDEIS and any of the clinical or biological markers. However, all the patients with significant endoscopic lesions (defined by a CDEIS>6) had previous surgical intestinal resection and lesions involving the anastomosis. Patients with elevated CDAI and normal CRP have only mild mucosal lesions of CD. Most significant lesions may be observed at the anastomosis and proximal to it in previously operated patients. None of the biological markers tested was associated with these endoscopic lesions.

MEN1 family with a novel frameshift mutation

Multiple endocrine neoplasm type 1 (MEN1) syndrome predisposes to the development of endocrine and non-endocrine tumors with an autosomal dominant pattern of inheritance. Different mutations have been found throughout the gene with a variable phenotype expression. The proband, a Caucasian man, was admitted to our department in 2001, at the age of 51 because of a 1-yr history of diarrhoea and hypertension. He reported a previous intestinal resection for bowel occlusion with a histological diagnosis of unspecified mesenchymal neoplasia. He had also undergone a left adrenalectomy for a large nonfunctioning adrenal adenoma. Subsequently, he had suffered from gastralgia and melena; a gastroduodenoscopy showed an erosive gastritis. His family history was negative for endocrine disorders. On physical examination, multiple abdominal cutaneous lipomas and facial angiofibromas were observed. Biochemical screening revealed a primary hyperparathyroidism and an increase in circulating levels of PRL, chromogranin-A, gastrin and glucagon. The whole body computed tomography (CT) scan, the 111In-octreotide scan and the pituitary magnetic resonance imaging (MRI) did not reveal any abnormality. The presence of small neuroendocrine tumors was suspected by a positron emission tomography uptake in the epigastric region. The endoscopic ultrasound revealed a pancreatic lesion sized 1.1 cm that is under evaluation. Direct DNA sequencing analysis of the proband MEN1 gene revealed the 579delG frameshift mutation in the exon 3. The genetic screening of the family revealed the same mutation in 3 out of 5 offspring. The biochemical screening revealed some features of the MEN1 syndrome in all three of them. In conclusion, a novel frameshift MEN1 mutation was found in kindred with an apparently negative family history. Our experience confirms that MEN1 syndrome is a complex and underestimated condition, unless specifically investigated by trained specialists.

Azathioprine and mesalamine for prevention of relapse after conservative surgery for Crohn’s disease

Because the reoperation rate for Crohn's disease is high after resective surgery, use of conservative surgery has increased. Mesalamine was investigated for the prevention of postoperative relapse, with disappointing results. The role of azathioprine in the postoperative setting is unknown. We aimed to compare the efficacy and safety of azathioprine and mesalamine in the prevention of clinical and surgical relapse in patients who have undergone conservative surgery for Crohn's disease. In a prospective, open-label, randomized study, 142 patients received azathioprine (2 mg. kg -1. day -1 ) or mesalamine (3 g/day) for 24 months. Clinical relapse was defined as the presence of symptoms with a Crohn's Disease Activity Index score >200 and surgical relapse as the presence of symptoms refractory to medical treatment or complications requiring surgery. After 24 months, the risk of clinical relapse was comparable in the azathioprine and mesalamine groups, both on intention-to-treat (odds ratio [OR], 2.04; 95% confidence interval [CI], 0.89-4.67) and per-protocol analyses (OR, 1.79; 95% CI, 0.80-3.97). No difference was observed with respect to surgical relapse at 24 months between the 2 groups. In a subgroup analysis, azathioprine was more effective than mesalamine in preventing clinical relapse in patients with previous intestinal resections (OR, 4.83; 95% CI, 1.47-15.8). More patients receiving azathioprine withdrew from treatment due to adverse events than those receiving mesalamine (22% vs. 8%; P = 0.04). While no difference was observed in the efficacy of azathioprine and mesalamine in preventing clinical and surgical relapses after conservative surgery, azathioprine is more effective in those patients who have undergone previous intestinal resection.

New perspective for the management of near-total or total intestinal aganglionosis in infants

Background Purpose: Extensive intestinal aganglionosis is rare. The diagnosis and treatment are known to be difficult and it had been considered to be fatal. The aim of this study was to review our experience with children with extensive intestinal aganglionosis. Methods: Retrospective analysis was conducted in patients referred to the intestinal transplantation unit since 1993. Presentation and outcome were analysed looking at 2 groups who had either undergone previous subtotal intestinal resection (group I) or no or limited resection (group II). Results. Eight children were selected (3 patients in group I and 5 in group II). Group I was remarkable in that patients all were referred early in age with progressing liver failure. Parents of one patient refused to accept transplantation as treatment, and he died one month later. Two noncirrhotic patients were maintained in the parenteral nutrition programme and currently progress well with enteral feedings. The other 5 patients underwent transplant, and 4 of 5 are alive after transplantation with a mean follow-up of 22.2 months (range 0.4 to 63.6). Conclusions: Subtotal resection of intestine at the time of diagnosis must be avoided. Conservative management with parenteral nutrition may be associated with long-term good outcome. Small bowel transplant may open new perspective in the management of patients with end-stage liver disease. J Pediatr Surg 38:25-28. Copyright 2003, Elsevier Science (USA). All rights reserved.

Clinical relevance of serum interleukin-6 in Crohn's disease: single point measurements, therapy monitoring, and prediction of clinical relapse.

To investigate the clinical relevance of interleukin-6 (IL-6) serum levels in patients with Crohn's disease (CD), single point IL-6 measurements in sera from consecutive CD patients and healthy donors (HD), as well as longitudinal measurements during the course of steroid therapy for active CD were performed. Patients with steroid-induced remission were followed until clinical relapse. One hundred thirty-six CD patients without steroid or other immunosuppressive treatment within 2 months and surgical procedures within 3 months before study entry were investigated; 63 patients with active CD were enrolled into the follow-up program. Clinical activity was evaluated by the Crohn's disease activity index (CDAI) and serum IL-6 levels measured by enzyme-linked immunosorbent assay. IL-6 serum levels were significantly elevated in CD patients compared to HD (p < 0.001). In individual patients serum IL-6 levels correlated with corresponding CDAI scores in a subgroup referred to as primarily inflammatory patients presenting without bowel stenosis, previous intestinal resection, or concomitant inflammatory disorders (r = 0.72, p < 0.001). Primarily inflammatory patients displayed higher serum IL-6 levels (median: 6.0 pg/ml; range: 1.3-25) than CD patients with bowel stenosis (median: 2.0; range: 1.3-4.9; p < 0.01) or extensive intestinal resection (median: 1.5; range: 1.3-13.7; p < 0.001). Longitudinally measured serum IL-6 levels reflected the clinical response during steroid therapy and predicted clinical relapse after steroid-induced remission at week 9 of the treatment protocol. Serum IL-6 is a clinically relevant parameter for CD that correlates with inflammatory activity and implies a prognostic value after steroid-induced remission.

Clinical relevance of serum interleukin-6 in Crohn’s disease: single point measurements, therapy monitoring, and prediction of clinical relapse

OBJECTIVE: To investigate the clinical relevance of interleukin-6 (IL-6) serum levels in patients with Crohn’s disease (CD), single point IL-6 measurements in sera from consecutive CD patients and healthy donors (HD), as well as longitudinal measurements during the course of steroid therapy for active CD were performed. Patients with steroid-induced remission were followed until clinical relapse. METHODS: One hundred thirty-six CD patients without steroid or other immunosuppressive treatment within 2 months and surgical procedures within 3 months before study entry were investigated; 63 patients with active CD were enrolled into the follow-up program. Clinical activity was evaluated by the Crohn’s disease activity index (CDAI) and serum IL-6 levels measured by enzyme-linked immunosorbent assay. RESULTS: IL-6 serum levels were significantly elevated in CD patients compared to HD ( p < 0.001). In individual patients serum IL-6 levels correlated with corresponding CDAI scores in a subgroup referred to as primarily inflammatory patients presenting without bowel stenosis, previous intestinal resection, or concomitant inflammatory disorders (r = 0.72, p < 0.001). Primarily inflammatory patients displayed higher serum IL-6 levels (median: 6.0 pg/ml; range: 1.3–25) than CD patients with bowel stenosis (median: 2.0; range: 1.3–4.9; p < 0.01) or extensive intestinal resection (median: 1.5; range: 1.3–13.7; p < 0.001). Longitudinally measured serum IL-6 levels reflected the clinical response during steroid therapy and predicted clinical relapse after steroid-induced remission at week 9 of the treatment protocol. CONCLUSIONS: Serum IL-6 is a clinically relevant parameter for CD that correlates with inflammatory activity and implies a prognostic value after steroid-induced remission.

The prevalence of gallstone disease in a defined cohort of patients with Crohn’s disease

OBJECTIVE: Crohn’s disease (CD) is associated with a high prevalence of gallstone disease but the relative risk has not been completely established. Ileal disease or resection have been considered as contributing factors to the increased risk. The aim of this study was to evaluate the prevalence of gallstone disease in a defined cohort of CD patients, to evaluate possible risk factors, and to evaluate the relative risk compared with the general population. METHODS: All inhabitants in Stockholm County born in 1933–1935 or 1953–1955, with CD diagnosed between 1955–1989 and not having had a previous cholecystectomy, were invited for an ultrasonography of the gallbladder. The prevalence of gallstone disease was related to disease extent, previous intestinal resections, age, and gender. The relative risk of developing gallstones was calculated using a recent study of gallstone disease in general, with similar age groups as controls. RESULTS: We found that 26.4% had gallstone disease (relative risk [RR] = 1.8; 95% confidence interval [CI], 1.2–2.7). The number of previous intestinal resections was the only significant risk factor. There was no significant difference in gallstone disease between gender (28.2% vs 24.1%) or age (34% vs 21.8%). CONCLUSIONS: Patients with Crohn’s disease, regardless of gender and age, have almost a doubled risk of developing gallstone disease compared with the general population. Circumstances related to laparotomy may contribute to the increased risk. The lack of association between the disease extent and the site of previous intestinal resection, together with a previous finding of normal cholesterol saturation of the bile in patients with CD, indicate that these patients may develop pigment stones rather than cholesterol stones.

The prevalence of gallstone disease in a defined cohort of patients with Crohn's disease.

Crohn's disease (CD) is associated with a high prevalence of gallstone disease but the relative risk has not been completely established. Ileal disease or resection have been considered as contributing factors to the increased risk. The aim of this study was to evaluate the prevalence of gallstone disease in a defined cohort of CD patients, to evaluate possible risk factors, and to evaluate the relative risk compared with the general population. All inhabitants in Stockholm County born in 1933-1935 or 1953-1955, with CD diagnosed between 1955-1989 and not having had a previous cholecystectomy, were invited for an ultrasonography of the gallbladder. The prevalence of gallstone disease was related to disease extent, previous intestinal resections, age, and gender. The relative risk of developing gallstones was calculated using a recent study of gallstone disease in general, with similar age groups as controls. We found that 26.4% had gallstone disease (relative risk [RR] = 1.8; 95% confidence interval [CI], 1.2-2.7). The number of previous intestinal resections was the only significant risk factor. There was no significant difference in gallstone disease between gender (28.2% vs 24.1%) or age (34% vs 21.8%). Patients with Crohn's disease, regardless of gender and age, have almost a doubled risk of developing gallstone disease compared with the general population. Circumstances related to laparotomy may contribute to the increased risk. The lack of association between the disease extent and the site of previous intestinal resection, together with a previous finding of normal cholesterol saturation of the bile in patients with CD, indicate that these patients may develop pigment stones rather than cholesterol stones.

The impact of surgery on health related quality of life in Crohn's disease

When patients with Crohn's disease (CD) express concerns about their disease, they emphasize worries about surgery. However, postsurgical changes in health related quality of life (HRQOL) in patients with CD have been barely studied, and published results are somewhat discrepant. In the present study we assessed whether surgical treatment of refractary or complicated CD modifies HRQOL. Outcomes of 27 patients with previous intestinal or colonic resection were compared to 39 non-operated patients and to a reference control group of 63 healthy individuals. All patients were in clinical remission at the time of study. Age and sex were similar in the three groups. Mean CD recurrence/year index was similar for operated and nonoperated patients, but the interval from diagnosis to interview was longer in operated patients (median [95% CI]: 100 [81-160] months vs 48 [46-78], p<0.01). HRQOL was assessed by a validated spanish version of the Inflammatory Bowel Disease Questionnaire (IBDQ), that included five dimensions: intestinal symptoms, general symptoms, emotional, social and functional. A general HRQOL questionnaire (Psychological General Well Being Index -PGWBI-) and a visual analogue scale (VAS) of HRQOL were also administered to CD patients. RESULTS: Analysis of variance showed that both operated and non-operated CD patients scored lower, indicating a poorer HRQOL, than controls in global IBDQ and all five dimensions. However, neither global score, digestive and systemic symptoms, emotional and functional dimensions differed significantly between operated and nonoperated CD patients. PGWBI and VAS were also similar in both groups of CD patients (101 [93-106] vs 104 [97-107] and 85 [71-85] vs 80 [75-84] respectively). Only the social dimension of IBDQ was scored lower by operated vs non-operated CD patients (6.2 [4.8-6.8] vs 6.5 [4.3-7.0], p=0.01). In conclusion, although CD impairs the HRQOL, as compared to healthy controls, surgical treatment of CD patients does not worsen their HRQOL except in social dimension.

Clinical Utility of In-111 Leukocyte Imaging in Crohnʼs Disease

Thirty six patients with Crohn's disease were studied with In-111 leukocyte imaging. There was a correlation of the presence of activity on early (4 hour) imaging (r = 0.516, P < 0.001) and on delayed 18-24 hour) imaging (r = 0.457, P < 0.003). In the total group of 36 patients, the results of imaging were useful in the immediate management of 13 patients (36.1%). These included four patients (11.1%) who refused to undergo colonoscopic examination and nine patients (25%), six of whom had previous intestinal resection.

Importance of endoscopically visualized recurrent ileitis and small bowel resection for symptoms in Crohn's disease

Background: The relationship between the endoscopic appearance of the ileal mucosa in Crohn's disease and the symptoms has not been studied. Although surgery is important, morbidity caused by intestinal resections and its relation to recurrent inflammation have been poorly evaluated. Methods: The relationship of symptoms to various ileoscopic signs of inflammation and previous intestinal resection was prospectively studied in 75 postresection Crohn patients. Results: Multivariate analysis showed that a combination of anastomotic width, pus, and length of previous small-bowel resection best explained a symptom score (r = 0.53, p < 0.001). Of 40 patients with the anastomosis strictured to less than 15 mm, only 9 had moderate to severe symptoms. Patients with a stricture diameter < 10 mm differed significantly in symptom score (p < 0.05) from those with wider anastomoses. Conclusions: The study indicated that intestinal resection was as important for symptoms as endoscopically viewed recurrent ileal inflamma...

Importance of endoscopically visualized recurrent ileitis and small-bowel resection for symptoms in Crohn's disease.

The relationship between the endoscopic appearance of the ileal mucosa in Crohn's disease and the symptoms has not been studied. Although surgery is important, morbidity caused by intestinal resections and its relation to recurrent inflammation have been poorly evaluated. The relationship of symptoms to various ileoscopic signs of inflammation and previous intestinal resection was prospectively studied in 75 postresection Crohn patients. Multivariate analysis showed that a combination of anastomotic width, pus, and length of previous small-bowel resection best explained a symptom score (r = 0.53, p < 0.001). Of 40 patients with the anastomosis strictured to less than 15 mm, only 9 had moderate to severe symptoms. Patients with a stricture diameter < 10 mm differed significantly in symptom score (p < 0.05) from those with wider anastomoses. The study indicated that intestinal resection was as important for symptoms as endoscopically viewed recurrent ileal inflammation. The diameter at which an intestinal stricture produces symptoms is less than previously argued, and the association of small-bowel resection with symptoms underlines the advisability of minimal surgery.

Pathogenesis of gall stones in Crohn's disease: an alternative explanation.

The increased prevalence of gall stones in Crohn's disease is thought to be related to depletion of the bile salt pool due either to terminal ileal disease or after ileal resection. This study was designed to examine whether this hypothesis is correct and explore alternative explanations. Two hundred and fifty one randomly selected patients (156 females, 95 males, mean age 45 years) were interviewed and screened by ultrasonography to determine the prevalence of gall stones in a large population of patients with Crohn's disease. Sixty nine (28%) patients had gall stones proved by ultrasonography (n = 42), or had had cholecystectomy for gall stone disease (n = 27). The risk factors for the development of gall stones including sex, age, site, and duration of disease, and previous intestinal resection were examined by multivariate analysis. Age and duration of disease were positive risk factors for gall stones and were covariables. The site of disease and of previous intestinal resection did not predispose to gall stones. Previous surgery was an independent risk factor for the development of gall stones, the risk increasing with number of laparotomies. It is suggested that mechanisms other than ileal dysfunction may predispose to gall stones. Postoperative gall bladder hypomotility with biliary sludge formation may be precursors of gall stone formation in patients with Crohn's disease.

Virulence properties of Escherichia coli strains isolated from patients with inflammatory bowel disease.

Escherichia coli strains cultured from 74 patients with inflammatory bowel disease at different stages of disease activity (Crohn's disease (40), ulcerative colitis (34)) and 18 healthy controls were studied in relation to haemolysin and verotoxin production and enteroadherence. Disease activity was assessed by standard clinical and laboratory tests. Haemolytic E coli were isolated from 18% of patients with Crohn's disease, 24% with ulcerative colitis, and 11% of healthy controls. None of these differences was significant. No verotoxin producing strains were detected among the 216 E coli isolates examined but the extract from five strains (Crohn's (4), ulcerative colitis (1) produced a distinctive cytopathic effort on Vero cell monolayers which was later shown not to be due to verotoxin. The adhesion indices of E coli isolates cultured were: mean (SEM) 42.2 (6.4) for Crohn's disease, 43.3 (6.2) for ulcerative colitis, and 11.3 (2.0) for normal controls (p less than or equal to 0.0001). Adhesive E coli were isolated from 62% of patients with Crohn's disease and 68% with ulcerative colitis but from only 6% of normal controls (p less than or equal to 0.0002). Neither haemolysin production nor enteroadherence was dependent upon disease activity, disease location, sulphasalazine treatment, or previous intestinal resection. These results indicate that only enteroadherent E coli were frequently associated with inflammatory bowel disease; their relation to the pathogenesis of these conditions, however, remains uncertain.

Long‐term effects of elemental and exclusion diets for Crohn's disease

Previous studies have confirmed the therapeutic value of elemental diets in promoting remission in active Crohn's disease, but their long-term benefit has not been established. Twenty-seven patients with established Crohn's disease who attained clinical remission after four weeks of enteral feeding were followed prospectively for up to 36 months. Twenty of these were willing to be tested for specific food intolerance using a pre-defined dietary elimination protocol; the others continued on a normal unrestricted diet. Eighteen patients (67%) have since relapsed; 89% of the relapse occurred within the first 6 months. Of the 15 patients with colonic involvement, 12 (80%) relapsed by 6 months. In contrast only 3 of 11 with isolated small bowel disease experienced early relapse. Of the 14 patients who completed the process of dietary testing, 5 could not identify any trigger foods; the remaining 9 were maintained on exclusion diets, 3 of whom relapsed early. Of the 11 taking a normal diet, 9 relapsed. Disease duration, previous intestinal resection or prior steroid therapy did not affect the relapse rate. Eight patients (31%) obtained a long-term remission, mean 23 months (range 12-36 months), without any medication. Long-lasting remissions can be obtained in about one-third of patients with Crohn's disease following treatment with a defined formula diet. Colonic involvement is associated with a high early relapse rate.

Exaggerated response of thyrotropin to thyrotropin-releasing hormone in patients resected for Crohn's ileitis.

We have studied the response of thyrotropin to exogenous thyrotropin-releasing hormone in 13 patients who had previous intestinal resection for Crohn's disease, and in 42 healthy controls. An exaggerated and prolonged response curve was found in eight of the patients and one control (P less than 0.01), while baseline hormone levels were normal in all. These results may be related to the state of iodine deficiency known to develop in inflammatory bowel disease, but the pathophysiology requires further elucidation.

NEPHROLITHIASIS IN CHILDHOOD INFLAMMATORY BOWEL DISEASE

Nephrolithiasis is an infrequent complication of inflammatory bowel disease (IBD) in children. Five patients have been managed at our institution since 1978. Their mean age at stone passage was 12.2 years and mean duration of active IBD was 33 months. The majority had ulcerative colitis, passed calcium phosphate stones, and developed nephrolithiasis during an acute exacerbation of IBD. Only one patient had a previous intestinal resection; no patient had a history of urinary tract infections. We have initiated a prospective evaluation of urinary crystalloid excretion in all newly diagnosed cases of IBD. Twenty-four hour urine determinations at diagnosis in 6 patients were within the normal range for calcium (mean = 151 mg), uric acid (338 mg) and oxalate (24 mg). One month after the initiation of therapy, there was an elevation in mean urinary calcium (222 mg) and uric acid (630 mg) excretion in 4 children receiving daily prednisone and salicylazosulfapyridine (SASP). These differences were not observed in 2 patients receiving SASP alone (calcium, 142 mg; uric acid, 374 mg). The effect of prednisone on calcium excretion is well described but its role in uric acid excretion is poorly understood. Further attention must be paid to the urinary excretion of various crystalline species throughout the course of IBD to prevent the complication of nephrolithiasis.

Recurrence and reoperation for Crohn's disease: the role of disease location in prognosis.

THE development of recurrent Crohn's disease after an intestinal resection has been estimated to occur in 3 per cent1 to 100 per cent2 of patients. This variation is associated with many factors, among which are the precise definition of recurrence, the location of the disease, and the methods of follow-up and data analysis. However, one of the most important clinical features of a recurrence is the likelihood of an additional intestinal resection. In order to define this problem more clearly, we investigated the incidence of histologically proved recurrent disease requiring additional surgical resection after a previous intestinal resection for Crohn's . . .