Gut  1988 May;29(5):588-92 

Perforating and non-perforating indications for repeated operations in Crohn's

disease: evidence for two clinical forms.

Greenstein AJ, Lachman P, Sachar DB, Springhorn J, Heimann T, Janowitz HD,

Aufses AH Jr.

Department of Surgery, Mount Sinai School of Medicine of the City University of

New York, NY.

The surgical indications in 770 patients with Crohn's disease undergoing

intestinal resection at The Mount Sinai Hospital from 1960-83 have been

reviewed. Surgical indications were divided into two principal categories: 375

cases with perforating indications and 395 cases non-perforating. Among 292

patients who underwent second operations for recurrent Crohn's disease, the

indications for second operation were closely dependent on the indication for

primary resection. Second operations were undertaken for perforating indications

much more often among cases where the initial indication had been perforating,

than among those whose initial indications had been non-perforating (73% v 29%,

p less than 0.00001). This trend to similarities in the indications which bring

patients to surgery was maintained within each anatomical category of Crohn's

disease and even between second and third operations (p less than 0.001).

Operations for perforating indications were followed by reoperation

approximately twice as fast as operations for non-perforating indications,

whether going from first to second operation (perforating 4.7 v non-perforating

8.8 years, p less than 0.001), or from second to third (perforating 2.3 v

non-perforating 5.2 years, p less than 0.005). Crohn's disease thus seems to

occur in two different clinical patterns, independent of anatomic distribution.

These are a relatively aggressive perforating type and a more indolent

non-perforating type, which tend to retain their identities between repeated

operations and to influence the speed with which reoperation occurs.