2005 Abstracts: Crohn's Disease (CD) Developing After Surgery for Ulcerative Colitis (UC) or Indeterminate Colitis (IC) Comparison of Evolution After Colectomy and Ileorectal Anastomosis (IRA) and Ileal Pouch Anal Anastomosis (IPAA)
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Crohn's Disease (CD) Developing After Surgery for Ulcerative Colitis (UC) or Indeterminate Colitis (IC) Comparison of Evolution After Colectomy and Ileorectal Anastomosis (IRA) and Ileal Pouch Anal Anastomosis (IPAA)
Isabelle Nion-Larmurier, Pauline Afchain, Laurent Beaugerie, Jean-Pierre Gendre, Gastroenterologie, Paris, 75, France; Emmanuel Tiret, Chirurgie, Paris, 75, France; Rolland Parc, Chirurgie, Paris, 75; Jacques Cosnes, Hopital St-Antoine, Paris, PARIS, 75, France
Some patients operated on for UC or IC will develop CD-like features. Long-term prognosis of these patients according to the type of surgery, IRA or IPAA, has not been studied yet.
75 patients operated on for UC or IC (database of 1736 patients with UC or IC, 484 operated on) developed new lesions after surgery, leading to reconsider the diagnosis from UC or IC to certain or plausible CD : perianal ulcers or fistulae (n=46), peculiar small bowel lesions (pouchitis excluded) (n=42), or epithelioid granuloma (n=13). Evolution was compared whether the patients have had IRA (n=36) or IPAA (n=39). Within the period 1995 to 2004, the patients were followed-up prospectively and each patient-year was ranked active or inactive according to the occurrence of a flare-up, disabling symptoms, or need for surgery. Results : The IRA and IPAA groups were not different respectively for the age at colectomy (median 25 vs. 31 yrs), gender (14 vs. 11 males), familial history, ethnicity, smoking habits, preoperative diagnosis (28 UC, 8 IC vs. 35 UC, 4 IC). However, more IRA than IPAA within the first year following diagnosis (14 vs. 5, p=0.02). Median follow-up was longer after IRA (13 yrs) than after IPAA (10 yrs, p<0.01). The later development of perianal and small bowel Crohn's disease lesions, respectively, was not different between IRA and IPAA : 19 (53%) and 22 (61%) after IRA, and 27 (69%) and 20 (51%) after IPAA (NS). After IRA, 18 patients (50%) received immunosuppressants and 5 (14%) infliximab, vs. after IPAA, 28 (72%, p=0.05) and 10 (26%, NS), respectively. A permanent ileostomy had to be performed in 7 IRA and 12 IPAA patients (NS). The 10-yr cumulative risk of permanent ileostomywas 19 ± 7 % after IRA, vs. 22 ± 7 % after IPAA (log rank p=0.09). During the 1995-2004 period, the proportion of active patient-years was higher after IPAA (125 out of 238, 53%) than after IRA (81 out of 220, 37%) (p<0.001). At last visit, 19 IRA patients (56%, 2 lost to follow-up) and 21 IPAA patients (55%, 1 lost to follow-up) had none orminor symptoms, without a permanent stoma. Conclusion : The development and the location of CD features after surgery for UC or IC do not depend on the type of colectomy. IPAA patients have a more active disease, requiring immunosuppressants more often than IRA patients. Nevertheless, regardless to the type of surgery, conservative medical treatment may control half of the patients and the need to perform a permanent stoma is infrequent.
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