Rapid Re-Operation For Crohn's Disease
Mary Otterson, KR Theriot, David Binion, D Thameem, S Shidham, OA Hatoum, Sarah Lundeen, Gordon Telford; Medical College of Wisconsin, Milwaukee, WI
Background: A subpopulation of Crohn’s Disease (CD) patients requires rapid re-operation. We analyzed multiply resected pts to characterize the factors contributing to rapid re-operation. Methods: Consecutive CD pts requiring multiple surgeries (resection & anastomosis &/or strictureplasty) at a tertiary IBD center over 7 y were reviewed. Rapid re-operation was defined as repeat abdominal surgery within 2 y. Operations at outside institutions & our facility were analyzed. Demographic data & medical therapy were recorded. Factors contributing to rapid re-operation were defined as technical, adhesions, inadequate immunomodulator therapy (IMT) & severe disease despite IMT. Technical was defined as retained strictures & stenotic anastomoses. IMT included azathioprine/6MP, methotrexate & or infliximab. Pts with insufficient 6MP metabolites were included as inadequate therapy. Results: 432 CD patients were reviewed; 65 pts required > 2 surgeries (200 abdominal operations). 32 of these pts required re-operation within 2 y (50 surgeries). There was no significant difference in gender, smoking status, disease location & age of onset between groups. Time between diagnosis & 1st surgery did not predict rapid re-operation. There were 27 rapid re-operations in the 1st post-op y (technical - 30%, adhesions - 4%, inadequate IMT - 47%, severe disease despite IMT - 19%). Between y 1 - 2, there were 23 rapid re-operations. In this group, the technical error contributed to 13% and severe disease despite IMT - 9%; inadequate IMT was linked to the majority of these rapid re-operations (78%). Pts who underwent rapid re-operation were more likely to undergo additional surgical procedures < 2 years. The operative interval for all surgical procedures for pts who had undergone rapid re-operation was 2.9+4.5 y (mean+SD) compared to those pts who had never had rapid re-operation (7.6+4.9 y). Rapid re-operation pts had a similar number of surgical procedures to those with longer time intervals between procedures (rapid 3.0+1.2 surgeries; longer interval 2.9+1.3 surgeries). The interval between procedures 1 through 4 is significantly shorter in pts who have ever been categorized as rapid re-operative (p<0.05; Mann Whitney). Conclusions: Crohn’s disease pts requiring rapid re-operation exhibit a distinct clinical pattern. Technical problems caused re-operation in 1/3 of pts in y 1 following laparotomy but only accounted for 13% of rapid re-operation by y 2. Lack of effective IMT became the dominant factor associated with rapid re-operation during post-op y 2. Pts who require rapid re-operation for CD continued to require more frequent surgeries & represent a more ill subset of pts.
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