Risk Factors of Surgical Recurrence after Resection for Crohn�s Disease

Special Article - Crohn’s Disease and Colitis

Austin J Gastroenterol. 2017; 4(3): 1084.

Risk Factors of Surgical Recurrence after Resection for Crohn’s Disease

Makni A*, Magherbi H, Heni AE, Haddad A, Awali M, Daghfous A, Ksantini R, Fteriche F, Jouini M, Kacem M, Rebai W, Daghfous A and Safta ZB

Department of General Surgery ‘A’, La Rabta Hospital, Tunisia

*Corresponding author: Makni Amin, Department of General Surgery ‘A’, La Rabta hospital, Tunis El Manar University, Jabbari 1007, Tunis, Tunisia

Received: February 14, 2017; Accepted: June 02, 2017; Published: June 21, 2017


Objective: The surgery is required in more than 80% of patients with Crohn’s disease. Crohn’s disease is associated with high rates of postoperative recurrence. The aim of the study was to identify, the risk factors of postoperative ‘surgical recurrence’ after the first resection for Crohn’s disease.

Methodology: We report a retrospective study from January 1998 to September 2010 that studied 226 patients originated only from Tunisia (in North Africa), operated on for MC. We had been interested to the risk factor of surgical recurrence of Crohn’s disease.

Results: Mean age was 33 years. The average time between the onset of the disease and the surgical procedure was 31 months. The diagnosis of CD was established preoperatively in 213 patients (94%). The diagnosis was made intraoperatively because of an acute complication in 5 cases (2.2%) and postoperatively in 8 cases (3.5%). The most common location was the ileocecal junction in 184 cases (81.4%). The most common type of lesion was the mixed form (stricture and fistula) in 123 cases (54.4%). Operative mortality was 0.04% (n=1). Specific morbidity was 8.4% (n=19). In long term, a surgical recurrence was noted in 18 patients (8%). In multivariate analysis, independent risk factors for recurrence were: smoking (p=0.012, ORs=3.57) and post-operative medical treatment (p=0.05, ORs=2.6).

Conclusion: Our series is unique for a lower rate of the postoperative recurrence (8%). The two risk factors of recurrence are smoking and the necessity of postoperative medical prophylaxis.

Keywords: Crohn’s disease; Surgery; Recurrence


The surgery is required in more than 80% of patients with Crohn’s disease (CD) [1]. The aim of surgery is to treat complicated lesions [2]. The most important principle of the surgery is to perform an intestinal resection as limited as possible. Crohn’s disease is associated with high rates of postoperative recurrence. At 10 years after surgery, 75% of patients suffer recurrence and 45% of these require re-intervention. The aim of the study was to identify, the risk factors of postoperative ‘surgical recurrence’ after the first resection for Crohn’s disease.


Study design and patient selection

This is a retrospective study, with prospective collection of data, conducted from January 1998 to September 2010, which included all patients undergoing surgery for primary CD. All patients born and living in Tunisia in North Africa. The diagnosis of CD was confirmed in all cases by histological examination of endoscopic biopsies or specimen after bowel resection. We excluded from this study, patients initially operated in another center and patients operated on for isolated anoperineal lesions of CD. The management was multidisciplinary and standardized for all patients.

Definition of ‘surgical recurrence’

Many definition of recurrence exist in the literature: endoscopic recurrence, clinical recurrence and surgical recurrence. We defined surgical recurrence as the need for repeat surgery [3].

Risk factors

All of the potential risk factors studied were divided in four groups. Factors related to the patient (cigarette smoking), to the disease (duration of disease, anatomical site of disease, type of disease: stricturing, penetrating, mixte or inflammatory disease), to the type of surgery (extend of bowel resection, the type of anastomosis and the involvement of section margins) and to the pharmacological treatment after surgery.

The postoperative course

A protocol was established to ensure regular monitoring during the postoperative period. Patients were followed both by the surgical team than gastroenterology. All results of clinical, biological and endoscopic have been noted and transcribed on patient records.

Statistical analysis

All data were reported as mean (with standard deviation (SD)) and/or median (with range value). The data were analyzed by means of SPSS 9.00 statistical package for Windows. Chi-square test (Fisher exact test in the case of small numbers) was used for group comparison and Student’s t test to analyze normally distributed quantitative data. P<0.05 was considered statistically significant.

The final date for follow-up was December 2015. Follow-up information was obtained regularly from outpatient clinical visits. To identify risk factors of the surgical recurrence of CD, we performed in the first step, univariate analysis: The survival rates and 95% confidence intervals [CI] were calculated using the Kaplan-Meier method. The Kaplan-Meier method was used for the management of patients lost who were considered as such during the follow-up. Differences in survival were compared by the Log Rank test. Next, the multivariate analysis was performed using Cox’s proportionalhazards regression model.


Characteristics of patients (with and without surgical recurrence)

The median age at diagnosis was 33.6 years (SD=12.2 years). They were 103 women and 123 men. The notion of smoking was present in 59 patients (26.1%).

In almost all cases (n=213, 94%), patients were monitored, before surgery, by a gastro-enterologist. Rarely, the diagnosis of CD was made during an emergency laparotomy performed for an acute complication (n=5, 2.2%) [Peritonitis (n=3), acute bowel obstruction (n=2)] or after histological examination of removed specimen (n=8, 3.5%) [Appendectomy (n=7), ileal resection for a migration of mesh in the gastrointestinal tract (n=1)].

Among the 226 patients, 102 (45.1%) were receiving at least one medical treatment for CD. Corticosteroid therapy was prescribed in 86 patients (38.1%), whereas the immunosuppressive treatment was prescribed in 23 patients (10.2%).

Anoperineal lesions were present in 45 patients (19.9%). One or more extra-intestinal manifestations were present in 39 patients (17.2%) [Rheumatologic (n=19), dermatological (n=12), ophthalmic (n=7), hematologic (n=3), hepatobiliary (n=2), nephrological (n=2), neurological (n=1) and gynecological such as primary infertility (n=1)].

Of the 226 patients, Crohn’s disease was complicated by intraabdominal abscess in 65 patients (28.8%).

Regarding the topography of lesions, the CD was single or multifocal. The distribution of the surgical lesions was ileocecal (n=184; 81%), colic (n=24; 10%), jejuno-ileal (n=10; 4%), appendicular (n=7; 3%) or duodenal (n=1; 0.4%) (Figure 1). Table 1 summarizes characteristics of fistulizing form of Crohn’s disease. Table 2 summarizes indications for operations in 226 patients with Crohn’s disease.