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To the Editor:

Development of new intestinal lesions in the neoterminal ileum after intestinal resection (postoperative recurrence [PR]) in Crohn's disease (CD) occurs in most patients.1 Active smoking, CD behavioral pattern, ileal involvement, and previous intestinal resections have been identified as risk factors for early PR.2 Luminal microbiota seems to play a relevant role in PR pathogenesis as suggested by the efficacy of nitroimidazolic antibiotics in preventing PR.3 Moreover, histological changes of PR occur soon after surgery but not if a protective loop ileostomy is present.4 Therefore, prophylactic strategies have been recommended to prevent or diagnose early PR in patients with ileocolonic anastomosis, but not in patients with permanent ileostomy.

With this perspective, we aimed to assess the rate of PR in CD patients with permanent ileostomy. We retrospectively reviewed the medical records of 16 patients with permanent ileostomy identified from our inflammatory bowel disease (IBD) database, among 284 CD patients who underwent intestinal resection. Disease location was colonic in 10 patients and ileocolonic in the remaining six, with inflammatory disease behavior in 12 out of 16. Seven patients (44%) kept on smoking after surgery. All patients with ileal involvement underwent ileocecal resection prior to proctocolectomy. Permanent ileostomy was performed after a median time of 78 months from CD diagnosis, and the main indication was treatment failure (six patients) and perianal disease (four patients). Thiopurine failure occurred in six cases (38%) and biological agents failed in three (18%). Ileal examination was performed immediately before proctocolectomy in nine patients (56%) by means of ileoscopy (n = 5), small bowel follow-through (n = 7), abdominal computed tomography (CT) scan (n = 2), or more than one of these techniques (n = 2). Preventive therapy with mesalamine or thiopurines was prescribed in seven and three patients, respectively.

After a median follow-up of 77 months (range, 45–142), clinical PR occurred in five patients (31%), meaning a risk of PR of 3.7 per 100 patient-years in patients with permanent ileostomy. Morphological PR at the terminal ileum was confirmed by CT scan or ileoscopy in all cases. The median time for clinical PR was 68 months (range, 41–102) and no clinical or epidemiological risk factors could be identified.

Clinical recurrence prompted drug therapy or treatment escalation in all cases (three adalimumab, one infliximab, one budesonide). A new intestinal resection was required in only one case because of a fibrotic stenosis with secondary periostomal fistula.

Our data suggest that clinical recurrence in CD patients with permanent ileostomy may occur in up to one-third of patients within 10 years after surgery. Scarce literature is available regarding morphologic or clinical recurrence. In the only study published to date to our knowledge, Onali et al5 retrospectively analyzed 38 patients with ileocolonic resection and different types of anastomosis. Overall, clinical recurrence was observed in 42% of patients, including five out of 14 (35%) with permanent ileostomy.

In conclusion, although it has been said that PR is less frequently observed in patients with ileostomy as compared to those with intestinal anastomosis, up to one-third will develop symptomatic PR in the former. Therefore, while waiting for the outcomes of larger series, it seems reasonable to assess PR in the ileum periodically with endoscopy or cross-sectional imaging techniques in CD patients with terminal ileostomy.

REFERENCES

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  • 1
    Nos P, Domènech E. Postoperative Crohn's disease recurrence: a practical approach. World J Gastroenterol. 2008; 14: 55405548.
  • 2
    Yamamoto T. Factors affecting recurrence after surgery for Crohn's disease. World J Gastroenterol. 2005; 11: 39713979.
  • 3
    Doherty GA, Bennett GC, Cheifetz AS, et al. Meta-analysis: targeting the intestinal microbiota in prophylaxis for post-operative Crohn's disease. Aliment Pharmacol Ther. 2010; 31: 802809.
  • 4
    Rutgeerts P, Geboes K, Peeters M, et al. Effect of faecal stream diversion on recurrence of Crohn's disease in the neoterminal ileum. Lancet. 1991; 338: 771774.
  • 5
    Onali S, Petruzziello C, Calabrese E, et al. Frequency, pattern, and risk factors of postoperative recurrence of Crohn's disease after resection different from ileo-colonic. J Gastrointest Surg. 2009; 13: 246252.

Carles Leal-Valdivieso MD*, Íngrid Marín MD*, Míriam Mañosa MD, PhD* †, Juan Enrique Naves MD*, Yamile Zabana MD* †, Marta Piñol MD, PhD‡, Eduard Cabré MD, PhD* †, Eugeni Domènech MD, PhD* †, * IBD Unit, Gastroenterology & Hepatology Badalona, Catalonia, Spain, † Centro de Investigaciones en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD) Badalona, Catalonia, Spain, ‡ Gastrointestinal Surgery Department Hospital Universitari Germans Trias i Pujol Badalona, Catalonia, Spain.