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Natural History of Crohn's Disease Following Total Colectomy and End Ileostomy

Lopez, Joanna MD*; Konijeti, Gauree G. MD, MPH*,†; Nguyen, Deanna D. MD*,†,‡; Sauk, Jenny MD*,†,‡; Yajnik, Vijay MD, PhD*,†,‡; Ananthakrishnan, Ashwin N. MD, MPH*,†,‡

doi: 10.1097/MIB.0000000000000072
Original Clinical Articles

Background: Crohn's disease (CD) requires surgical management in up to two-thirds of patients. Few studies have addressed the issue of ileal recurrence after colectomy and permanent ileostomy. The aims of our study were to assess the rate and predictors of postoperative recurrence of CD in patients with permanent ileostomy.

Methods: In a retrospective study from a tertiary referral center, we analyzed the natural history of patients with CD who underwent total colectomy and permanent ileostomy. Our primary outcomes were (1) overall disease recurrence including luminal recurrence, perianal disease or peristomal lesions requiring therapy, and (2) luminal recurrence alone defined as endoscopic and clinical recurrence within the terminal ileum. We examined if patient characteristics predicted recurrence using multivariate Cox proportional hazard models.

Results: Our study included 73 patients with CD followed for a mean of 28 months (range, 0–168 mo) after total colectomy and permanent ileostomy. Twenty patients had overall disease recurrence within 10 years after surgery, at rates of 15% and 50% at 1 and 5 years, respectively. Rate of luminal recurrence was 8% and 35% at 1 and 5 years, respectively. Diagnosis at age less than 18 years (hazard ratio, 2.94; 95% confidence interval, 1.14–7.62) and anti–tumor necrosis factor therapy before surgery (hazard ratio, 4.75; 95% confidence interval, 1.25–18.13) were the only independent predictive factors for overall disease recurrence.

Conclusions: Up to one-third of patients with CD have overall recurrence of disease after treatment with total colectomy and permanent ileostomy. There is need to develop algorithms for surveillance and management of this select subgroup of patients.

Article first published online 21 May 2014.Supplemental Digital Content is Available in the Text.

*Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts;

Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts; and

Harvard Medical School, Boston, Massachusetts.

Reprints: Ashwin N. Ananthakrishnan, MD, MPH, Division of Gastroenterology, Massachusetts General Hospital, 165 Cambridge Street, 9th Floor, Boston, MA 02114 (e-mail:

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

The authors have no conflicts of interest to disclose.

Supported by the National Institutes of Health (P30 DK043351) to the Center for Study of Inflammatory Bowel Diseases. A. N. Ananthakrishnan is supported in part by a grant from the National Institutes of Health (K23 DK097142).

Received March 03, 2014

Accepted April 8, 2014

© Crohn's & Colitis Foundation of America, Inc.
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