Background: Up to 85% of Crohn's patients will undergo surgical resection during the course of their disease. The majority of these resections involve ileocoecal resection. Smoking, fistulizing disease, and young age have been identified as risk factors for clinical and surgical postoperative recurrence. The prognostic impact of radicality of resection has been a matter of debate for decades, but so far current guidelines do not specifically recommend performing a radical resection. In contrast, they only emphasize the importance of a limited resection.
The aim of this study is to analyze the prognostic impact of pathological findings in the resection margins of ileocoecal resection specimens in Crohn's disease.
Methods: A consecutive series of 43 patients with Crohn's disease undergoing primary ileocoecal resection for medically refractory disease between 2006 and 2009 at the Academic Medical Center (AMC) in Amsterdam were included. Resection margins were histologically scored for several inflammatory parameters (e.g. architectural changes, eosinophils and neutrophils in lamina propria, crypt destruction, erosions and ulcerations, granulomes, and fissures). The score was based on the adjusted Geboes score. Pathological findings were correlated to clinical results that have been collected in a prospectively maintained database. Clinical recurrence was defined as endoscopic recurrence necessitating medical treatment.
Results: There were 12 men and 31 women with a median age of 33.3 years. Median follow-up time was 71 months, with a minimum of 58 months. A radical resection was performed in 65.1% of patients. No association between clinical parameters and non-radical resection could be demonstrated. Overall clinical recurrence rate was 41.9%, with a lower recurrence rate in the radically resected group (32.1% versus 67.9% in the non-radical group, p=0.06 log-rank). Kaplan Meier curves showed that the median time to recurrence was 18 months for both groups. The incidence of surgical recurrence was too small (n=1) to perform statistical analysis.
Conclusions: The presence of active microscopic inflammation in the resection margin after ileocoecal resection seems to be related to recurrent Crohn's disease. The high incidence of clinical recurrence in the non-radical group (68%) justifies a renewed discussion about the clinical importance of a radical surgical resection in these patients.