Surgical history of Crohn's disease in a well-defined population

Since 1935, 42 of 103 residents of Olmsted County, Minnesota, identified as having Crohn's disease underwent one or more surgical procedures. The incidence and type of surgical intervention, distribution of disease, and risk of recurrent disease after surgery were analyzed. Follow-up extended to 32 years, with a median of 8.5 years. Thirty-six patients underwent at least one definitive resection; eight of these patients subsequently underwent a second definitive operation. The likelihood that any patient would undergo operation was greatest within the first year of diagnosis. The proportion of patients in whom recurrent disease developed after the first and second definitive resections was 50% and 37%, respectively. Approximately half the patients who experienced a recurrence underwent further surgery. The site of diseased bowel and sex were not factors specifically influencing recurrence rates. Patients 40 years of age and older who underwent surgery appeared to fare better with respect to recurrent disease than young patients. Although our findings suggest cumulative risks of recurrent disease after definitive resection similar to those reported from larger population groups or major referral centers, the proportion of patients who underwent surgery during the natural history of their Crohn's disease was much less than generally reported. We conclude that operation for Crohn's disease is not inevitable and that evidence to the contrary may imply both a treatment and a referral bias.