The problem of postoperative recurrence of Crohn's disease

Most patients with Crohn's disease eventually require an operation and the overwhelming majority will ultimately experience a postoperative recurrence at the anastomotic site. Endoscopic lesions can be seen at the anastomosis in 85 per cent of patients by 3 years after surgery. While only 40 to 50 per cent of postoperative patients will ever undergo a second operation, clinical manifestations of recurrent disease develop at a cumulative rate of about 10 per cent per year. Postoperative recurrences of Crohn's disease are well recognized even after total proctocolectomy and ileostomy, but rates are higher following reanastomotic procedures. Evidence accumulated from published observations over the past 20 years, reinforced by new data from The Mount Sinai Hospital, suggests that Crohn's disease may follow at least two different patterns: "aggressive" disease characterized primarily by fistulae and abscesses, early requirement for surgery, and relatively rapid fistulizing-type recurrence; versus "indolent" disease characterized mostly by fibrotic stenosis and strictures, late requirement for surgery, and relatively slower obstructive-type recurrence. Pathophysiologic investigations and clinical trials alike should take into account this duality of clinical patterns. Regardless of the patterns of recurrence, however, surgery performed for proper indications is almost invariably rehabilitating for people disabled by the ravages and complications of Crohn's disease.