- [Narrator] The University of Michigan
Division of Gastroenterology
and the Inflammatory Bowel Disease Program
host the IBD Visiting Professor Lecture Series
in Ann Arbor, Michigan.
This series presents the latest in clinical research
and basic science from IBD experts from around the world.
- I wasn't really quite sure what to talk about
when Peter asked me to talk about my research
because I don't really have anything really new and exciting
I wouldn't say, so I've put together sort of a,
bit of a compilation of some of the things that I've done
and then I'm going to end up with a few opinions on this,
which maybe I should just shut up about,
but you're going to get my opinions
so you're gonna have some evidence and some opinion.
So I thought that I would talk about
the recurrence rates following surgery
and the variables which may modify the risk,
what surgeons can do to decrease the risk of recurrence,
and then get into some of the things
that I think are important
as we talk about maintenance therapy.
Can you not hear me?
- [Female student] Not in the back.
- Turn the lights down. - That microphone's just
for the camera.
- Okay, so I'll just talk louder then.
And some of the issues that I think are important
that we need to deal with related to maintenance therapy.
So generally, surgery is reserved for treating
Crohn's disease unlike ulcerative colitis for treating
the complications of the disease
and occasionally for failure of medical treatment
and I think that it's really important
to point out that multiple studies have shown that
surgery usually results in excellent quality of life
in patients, it eliminates the symptoms of complications
and although, people worry about repeated operations,
rarely less than 1% of patients have problems
with short gut and therefore,
I think that it's important to point out
that surgery should not be considered a failure
rather that we need to think of the management
of Crohn's disease as a multi-disciplinary disease
and both medication and surgery have a role.
However, we also need to realize that recurrence
of disease following surgery occurs frequently
and when it does occur, it impacts negatively
on quality of life.
So, to me, this is really one of the important,
very important issues in Crohn's disease prevention
or at least treatment of recurrence of Crohn's disease.
Now, the recurrence rates, probably most of you know this,
it varies depending on how we define recurrence,
whether it's endoscopic, symptomatic or reoperative rates,
endoscopic rates of 75-90% have been reported at one year
but I would say that probably more reasonable
or more important or what we would call severe lesions,
say Rudgard's two or three in higher lesions
and they're seen in approximately 35%
of patients at one year.
Symptomatic recurrence rates varies from 7-25% at one year.
Patients really vary but by 5 years,
approximately 50% will have clinical recurrence
and reoperative rates for recurrence
are somewhere around 3-5%
so here's just a study that we did in
the placebo group and you can see it,
five years about 50% of patients had clinical
or symptomatic recurrence
so certainly not a small figure, you know,
it's a significant problem.
In fact, with our Gastroenterologist,
when I'm consulted to see a patient,
I always say: It's not if the patient surgery,
it's when the patient will need the surgery
and our Gastroenterologist smiles at me
and he says, "It's not if the disease will recur,
"it's when the disease will recur."
And I think those are important things to remember.
So, it's a little discouraging actually
in predicting who's going to get recurrence.
Some of the things that have been looked at
are the age of onset, the duration of the disease,
whether it's granulomata or present and those,
I think everyone agrees, are of no predictive value.
Some studies have suggested that ileal disease
is more likely to occur or Small Bowel disease
than colonic disease but that my also
just be a function of surgery as well.
A number of resections in our studies that we've done
that individuals who have had multiple resections
are more likely to have a recurrence of Crohn's disease
but that has not been consistently observed either.
And then, I want to just talk a little bit
about indication for surgery in genetic mutations
so the pattern of disease, meaning whether the patient
has inflammatory disease, stenosing or stricturing disease
or fistulizing disease has been sort of a hot topic
and whether you can predict who's going to get
recurrence depending on the pattern of disease
in this meta-analysis of 13 nonrandomized studies
which included about 3000 patients
and you can see here that they found
that the recurrence rate was higher in the group
having penetrating or fistulizing disease
and that reoperation, there was a concordance
in the disease type so that if you had
fistulizing disease as an indication in
your first operation, it was likely that
you would have it for the second operation.
I have to say that, I'll put my bias out there,
I'm not certain that I've really believed these data.
There's significant heterogeneity in these studies.
But to me the most important factor as a surgeon,
is that I think how you classify the disease,
varies depending on the stage of the disease
and in fact, we did a study where we had a group
of international experts, Gastroenterologists
who were experts in IBD and we showed them a series
of cases and we asked them to classify them
whether it was penetrating, inflammatory or stricturing
and the kappa for that or the agreement was about .29
and suggesting that if the experts have disagreement,
you know that I'm not certain just how good this is
but others feel that it does make a difference.
The other is genetic abnormalities and particularly
NOD2 is the mutation that we know most about
and in terms of recurrence that there were a few studies,
a few years ago that was suggestive that those who
had NOD2 mutation, were more likely to have
early post-operative recurrence and need for reoperation.
Again, small numbers retrospect of studies
more recently though, there have been some studies
that have refuted this or at least not supported this
so I think the great hope with the genetics of IBD,
that they still haven't been realized
and we still have hope that we will
be able classify patterns of disease
but I don't think we're just right there.
So in summary, I think that really
a lot of things that we hope,
could classify who's at high risk for developing
recurrence we haven't panned and it's difficult
to ascertain or to predict who will have early recurrence.
So, going on then, what can the surgeon do
to decrease the risk of recurrence?
And the first, is whether we do a stoma or anastomosis
and this is about the only thing that we can do as a surgeon
that we can make a difference, in terms of whether patients
develop a recurrence and this is a study that we did
and you can see that after six years of follow-up,
none of the patients who had a total proctocolectomy
had a recurrence whereas somewhere about 60%
of individuals who had a segmental resection
had developed a recurrence.
The problem with us, obviously, is that most patients,
if they were given the choice of
whether they were going to have a stoma or anastomosis,
they would probably take their chances
and want to have an anastomosis rather than a stoma.
And further more, it only applies to those patients with
colonic disease and not the vast majority
of patients who have ileal or ileocolic disease.