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Original Investigation |

Long-term Results and Recurrence-Related Risk Factors for Crohn Disease in Patients Undergoing Side-to-Side Isoperistaltic Strictureplasty

Marilena Fazi, MD1; Francesco Giudici, MD, PhD1; Cristina Luceri, PhD2; Micaela Pronestì, MD1; Francesco Tonelli, MD1
[+] Author Affiliations
1Department of Surgery and Translational Medicine, University of Florence, Careggi University Hospital, Florence, Italy
2Section of Pharmacology and Toxicology, Department of NEUROFARBA, University of Florence, Florence, Italy
JAMA Surg. 2016;151(5):452-460. doi:10.1001/jamasurg.2015.4552.
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Importance  Side-to-side isoperistaltic strictureplasty (SSIS) is useful in patients undergoing surgery for Crohn disease (CD) to avoid wide small-bowel resections. To our knowledge, there are no definitive data regarding its recurrence risk factors.

Objective  To evaluate the results obtained in a monocentric population of patients with CD who have undergone SSIS.

Design, Setting, and Participants  From August 1996 to March 2010, 91 patients with CD underwent SSIS in our center. In this prospective observational study, side-to-side isoperistaltic strictureplasty was according the Michelassi technique in 69 patients and the Tonelli technique in 22 patients. Factors relating to the patient and the CD, surgery, and pharmacological therapy during the preoperative and perioperative periods were evaluated in association with medical or surgical recurrence.

Exposure  Side-to-side isoperistaltic strictureplasty.

Main Outcomes and Measures  The recurrence-free curve was estimated using Kaplan-Meier analysis. Patients were stratified into cohorts in relation to the considered categorical variables and data were compared by using the Mantel-Cox log-rank test. Cox proportional hazard regression analysis was used to set up a predictive model simultaneously exploring the effects of all independent variables on a dichotomous outcome recurrence in relation to time.

Results  Among the 91 patients, the mean (SD) age was 39.5 (11.2) years and preoperative disease duration was 97.9 (85.8) months; 83 patients (91.2%) were followed up, of whom 37 (44.58%) experienced a recurrence at a mean (SD) of 55.46 (36.79) months after surgery (range, 9-140 months). The recurrence in the SSIS site at a mean (SD) of 48.25 (29.94) months after surgery affected 24 of 83 patients (28.9%), 9 being medical and 15 being surgical recurrence. Recurrence in the SSIS was statistically significantly associated with the time elapsed between diagnosis and surgery (P = .03). A borderline association between family history of CD and surgical recurrence (P = .054) was also found. Multivariate analysis identified the age at diagnosis (χ2 = 5.56; P = .02) and at surgery (χ2 = 7.77; P = .005), family history (χ2 = 6.26; P = .01), and smoking habit (χ2 = 10.06; P = .007) as independent risk factors for recurrence.

Conclusions and Relevance  In the short-term, SSIS leads to a resolution of symptoms in more than 90% of cases and the recurrence rate in the SSIS area is acceptable, even after long-term follow-up.

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Kaplan-Meier Time-to-Event Estimate Plots

A, Global recurrence based on family history, smoking, and disease location. Recurrence events were significantly negatively associated with cessation of smoking (P < .05) and with distal ileum-colon localization of the disease (P < .01). B, Surgical recurrence in side-to-side isoperistaltic strictureplasty (SSIS) based on family history of inflammatory bowel disease and disease location. Surgical recurrence in SSIS alone was associated with significant reduction in patients without a family history and with a disease localization in the distal part of the bowel.

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