Surgical improvements for Crohn's disease sufferers

Decades of painstaking research has yielded the most in-depth look ever at the management of bowel stricture recurrence in patients who undergo surgery for Crohn's disease. The findings should provide much-needed guidance to surgeons and gastroenterologists battling this tough-to-manage intestinal disorder.

Published in the journal Surgery, the study is the brainchild of Dr. Fabrizio Michelassi, chairman of the Department of Surgery and the Lewis Atterbury Stimson Professor of Surgery at Weill Cornell Medical College, and surgeon-in-chief at NewYork-Presbyterian Hospital/Weill Cornell Medical Center in New York City.

"These findings offer surgeons working with Crohn's patients a degree of clarity that just wasn't there before, and should greatly enhance the surgical management of this disease," says Dr. Michelassi, a world-renowned authority in surgical management of Crohn's.

Among other findings, the study supports the notion that strictureplasty -- a bowel-sparing surgical procedure commonly used to correct Crohn's-related strictures -- is less likely to lead to stricture recurrence later on, compared to surgical excision ("resection") of the stricture.

Crohn's disease involves a chronic inflammation of the digestive tract, often resulting in pain and diarrhea. Disease onset typically occurs in young adulthood, and the disorder is characterized by strictures -- narrowings of the bowel -- which often require surgical excision or correction. There is currently no cure for Crohn's, which affects about seven in every 100,000 Americans.

In decades past, Crohn's patients typically underwent surgical removal of the bowel at the point of stricture, although in recent years, corrective, bowel-sparing "strictureplasties" have become much more common. Dr. Michelassi has been a pioneer in developing new strictureplasty techniques. But he says that, up till now, surgeons lacked good information on the long-term consequences of these operations compared with resection.

Seeking to change all that, Dr. Michelassi launched his own prospective, longitudinal study more than 20 years ago.

"Beginning with my work as a young surgeon at the University of Chicago, I kept records from the very first patient I operated on with Crohn's disease in 1988. By 2001, I had already operated on more than a thousand patients," he explains. During each procedure, Dr. Michelassi took pictures and made detailed sketches of those areas subject to surgery. "So, if these patients came to me again 5 or 10 years later with a stricture recurrence, I could compare the location of the recurrence to the site of the original surgery," he says.

Surgeons know that about one-third of patients who undergo Crohn's-related surgery will have a recurrence. However, since most Crohn's patients are young and prone to moving from city to city, only a long-term study at a major center could track enough patients to get a good picture of post-op trends over time. During his nearly 20 years at the University of Chicago (1984-2004), Dr. Michelassi was able to keep records on 981 patients who underwent a total of 1,132 procedures, 668 of which involved recurrent disease.

The study yielded some interesting findings.

"First of all, it validated the notion that strictureplasty carries a lower risk of stricture recurrence compared to resection," Dr. Michelassi says. "And if a recurrence does occur after strictureplasty, it is likely to happen much later than after resection." Recurrences after strictureplasty were also less likely to require a surgical excision of the affected area compared to recurrences occurring after resection, he says.

The study also found that up to a third of recurrences occur away from the site of the original operation. Furthermore, the type and site of prior surgery appears to influence the pattern of recurrence, the researchers found. The study also provides new guidance on what surgeons call "prophylactic strictureplasty" -- procedures aimed at preventing stricture-related trouble.

"Sometimes we encounter a stricture that isn't giving the Crohn's patient any symptoms right now. We know, though, that these strictures can lead to trouble in about 25 percent of cases," Dr. Michelassi explains. "Based on our findings, we would now advise that if an asymptomatic stricture can be fixed using bowel-sparing strictureplasty, then the surgeon should go ahead and perform that type of prophylactic procedure," the NewYork-Presbyterian/Weill Cornell expert says. "However, if fixing the problem requires bowel resection, then we would advise leaving the stricture alone, because there's still a 75 percent chance it will not cause the patient any harm."

According to Dr. Michelassi, the study required years of careful data collection, but the results have been more than worth it. "There's never been anything before done on this scale, or with this level of precision. That's meant that -- up until now -- surgical management of this disease has been largely a matter of guesswork," he concludes. "These data are therefore tremendously important in helping Crohn's patients and their doctors decide which course of action might be best for them."

Dr. Michelassi's work received funding from the Alice Bohmfalk Charitable Trust. Co-authors include Dr. Stefano Lovadina, Dr. Fabrizio Cimino, Dr. Alessandro Fichera, Dr. Roger D. Hurst and Michele Rubin -- all of the University of Chicago.