Surgery in Crohn's disease: when, where and why the recurrences?

ABSTRACT

One frustrating feature in the surgical management of Crohn's disease is the high recurrence rate which may lead to reoperation. It is common opinion that relapses occur haphazardly both in time and in site, and the causes remain unknown. When does a recurrence really arise after surgery? Is the site of recurrence determined by definite causes? Is there a relapsing factor? Between 1965 and 1995, 177 patients underwent surgery for Crohn's disease. The procedures performed in 145 cases were those popular at the time, while a recent series of 20 selected patients was managed following a new approach based on epiploonplasty. This strategy stems from the strong conviction that Crohn's disease is not a primary bowel disease but the result of stasis and superimposed infection due to a primary hemolymphatic disorder of the mesentery. The five-year recurrence rate was 62% in patients operated on according to standard procedures, while no recurrences were reported in the epiploonplasty group. Among 12 remaining patients with recurrent disease, two cases are reported in detail because they provide evidence in favor of the hemolymphatic theory. This study also maintains that recurrences, viewed with the hemolymphatic disorder in mind, occur immediately after surgery, while the superimposed intestinal inflammatory process and stricturing events may appear clinically at different time intervals during follow-up. The site of recurrences usually corresponds to the mesenteric region subjected to compression. Altered mesenteric microcirculation appears to be the true essence of the disease.