A prospective, randomized assessment of a novel, local antibiotic releasing platform for the prevention of superficial and deep surgical site infections.

BACKGROUND: Despite significant advances in infection control guidelines and practices, surgical site infections (SSIs) remain a substantial cause of morbidity, prolonged hospitalization, and mortality among patients having both elective and emergent surgeries. D-PLEX100 is a novel, antibiotic-eluting polymer-lipid matrix that supplies a high, local concentration of doxycycline for the prevention of superficial and deep SSIs. The aim of our study was to evaluate the safety and efficacy of D-PLEX in addition to standard of care (SOC) in preventing superficial and deep surgical site infections for patients undergoing elective colorectal surgery. METHODS: From October 10, 2018 to October 6, 2019, as part of a Phase 2 clinical trial, we randomly assigned 202 patients who had scheduled elective colorectal surgery to receive either standard of care SSI prophylaxis or D-PLEX100 in addition to standard of care. The primary objective was to assess the efficacy of D-PLEX100 in superficial and deep SSI reduction, as measured by the incidence of SSIs within 30 days, as adjudicated by both an individual assessor and a three-person endpoint adjudication committee, all of whom were blinded to study-group assignments. Safety was assessed by the stratification and incidence of treatment-emergent adverse events. RESULTS: One hundred and seventy-nine patients were evaluated in the per protocol population, 88 in the intervention arm [51 males, 37 females, median age (64.0 range: 19-92) years] and 91 in the control arm [57 males, 34 females, median age 64.5 (range: 21-88) years]. The SSI rate within 30 day post-index surgery revealed a 64% relative risk reduction in SSI rate in the D-PLEX100 plus standard of care (SOC) group [n = 7/88 (8%)] vs SOC alone [n = 20/91 (22%)]; p = 0.0115. There was no significant difference in treatment-emergent adverse events. CONCLUSIONS: D-PLEX100 application leads to a statistically significant reduction in superficial and deep surgical site infections in this colorectal clinical model without any associated increase in adverse events.

Synchronous Hartmann reversal and incisional hernia repair is associated with higher complication rate compared to a staged procedure.

Post operative ventral hernias are common following Hartmann's procedure. There is a debate whether hernia repair is safe when performed concomitantly with colostomy closure. In this study we aimed to evaluate the outcomes of synchronous Hartmann reversal (HR) with a hernia repair, compared to a staged procedure. A retrospective multi-center study was conducted, including all patients who underwent Hartmann's procedure from January 2004 to July 2017 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome. Two hundred and seventy-four patients underwent colostomy reversal following Hartmann's procedure. In 107 patients (39%) a concomitant ventral hernia was reported during the Hartmann's reversal. Out of this cohort, 62 patients (58%) underwent hernia repair during follow-up. Thirty two patients (52%) underwent a synchronous hernia repair and 30 patients (48%) underwent hernia repair as a separate procedure. Post operative complication rate was significantly higher in the colostomy reversal with synchronous hernia repair group when compared to HR alone group (53% vs. 20%; p < 0.01; OR 4.5). In addition, severe complication rate (Clavien-Dindo score ≥ 3) was higher in the synchronous hernia repair group (25% vs. 7%). A tendency for higher hernia recurrence rate was noted in the synchronous group (56% vs. 40%). Median follow up time was 2.53 years (range 1-13.3 years). Synchronous colostomy closure and ventral hernia repair following Hartmann's procedure carries a significant risk for post operative complications, indicating that a staged procedure might be preferable.

Timing of colostomy reversal following Hartmann's procedure for perforated diverticulitis.

AIM: Hartmann's procedure is the surgical treatment of choice for perforated acute diverticulitis. Hartmann's reversal (HR) that is performed at a later stage may be challenging. The optimal timing for HR is still a subject for controversy. The aim of this study is to assess whether the timing of HR affects surgical outcome. PATIENTS AND METHODS: A retrospective-cohort multi-center study was conducted, including all patients who underwent HR for acute diverticulitis from January 2004 to June 2015 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome. RESULTS: One hundred and twenty-two patients were included in the database. Median time from Hartmann's procedure to reversal was 182.7 days, with the majority of patients (76 patients, 62.2%) operated 60 to 180 days from the Hartmann's procedure. Fifty-seven patients (46.7%) had post-operative complications, most commonly wound infections (27 patients, 22.1%). Receiver operating characteristic (ROC) curve and a propensity score match analysis (P=0.43) correlating between days to HR from the index procedure showed no specific cut-off point regarding post-operative complications (P=0.16), Major (Clavien-Dindo score of 3 or more) complications (P=0.19), Minor (Clavien Dindo 1-2) and no complications (P=0.14). Median length of stay was 10.9 days (range 3-90) and Pearson correlation failed to demonstrate a correlation between timing of surgical intervention and length of stay (P=0.4). CONCLUSION: Hartmann's Reversal is a complex surgical procedure associated with high rates of complications. In our series, timing of surgery did not affect surgical complications rate or severity or the length of hospital stay.

Reversal of Hartmann's procedure: still a complicated operation.

Hartmann's procedure, colonic resection with an end colostomy and rectal closure, is used in a variety of surgical emergencies. It is a common surgical procedure that is often practiced in patients with colonic obstruction and colonic perforation, resolving the acute clinical situation in the majority of cases. Reversal of Hartmann's procedure with restoration of bowel continuity occurs in a significantly low percentage of patients. There are several reasons contributing to the fact that many patients remain with a permanent colostomy following Hartmann's procedure. These include factors related to the patients' clinical status but also to the significant difficulty and morbidity related to the surgical reversal of Hartmann's procedure. The aim of this study was to review the factors related to the fairly low percentage of patients undergoing Hartmann's reversal as well as surgical techniques that could help surgeons restore intestinal continuity following Hartmann's procedure and deal with the postoperative outcomes.

Colonoscopy after the first episode of acute diverticulitis: challenging management paradigms.

BACKGROUND: Colonoscopy is commonly recommended after the first episode of acute diverticulitis to exclude colorectal neoplasia. Recent data have challenged this paradigm due to insufficient diagnostic yield. The aim of this study was to assess whether colonoscopy after the first episode of acute diverticulitis is needed to exclude colorectal neoplasia. METHODS: We performed a retrospective cohort analysis of medical records of patients admitted for the first episode of acute diverticulitis between January 2008 and December 2012. Ambulatory colonoscopy was routinely recommended at discharge. Clinical follow-up and telephone surveys were used for data collection. RESULTS: Four hundred and twenty-five patients with a mean age of 62.6 years (range 21-98 years) were admitted during the 5-year period. Three hundred and ten (72.9 %) patients underwent colonoscopy at median time of 3.2 months after discharge. Five patients (1.6 %) of the 310 available for evaluation had malignant findings in colonoscopy. Of those, one patient had rectal carcinoma away from the inflamed site and one had colonic lymphoma. None of the 95 patients <50 years of age was found to have adenocarcinoma of the colon. CONCLUSIONS: Cancer is rarely detected in colonoscopy following the first episode of acute diverticulitis. These results question this indication for colonoscopy, especially in patients under 50.

Diagnosis and management of splenic injury following colonoscopy: algorithm and case series.

BACKGROUND: Splenic injury following colonoscopy is a rare yet life-threatening complication. These injuries are often associated with delayed diagnosis and may require invasive intervention. We sought to study the emergent presentation associated with splenic injury post-colonoscopy and to suggest a new treatment algorithm. METHODS: Six cases of splenic injury following colonoscopy were collected from three medical centers. Data regarding patient medical history, clinical presentation, laboratory and imaging findings and clinical management were recorded. A systematic PubMed/MEDLINE search was performed. Non-English-language publications and publications dating earlier than 2010 were excluded. An emergency department trauma-based management algorithm was designed according to the identified publications and review of the available trauma literature. RESULTS: The mean age was 65.3 years and the male-to-female ratio was 1:5. Five of the cases presented within 24 h of the colonoscopy complaining of severe abdominal pain. Hemodynamic instability was noted in four patients who presented with tachycardia (105-130), hypotension and/or a rapid drop in hemoglobin levels. All of the patients underwent initial resuscitation and a computerized abdominal tomography scan. Four of them required emergent splenectomy. No mortality or major morbidity was reported following the hospitalization. CONCLUSIONS: Although very rare, splenic injury during colonoscopy is an acute, severe and possible fatal complication. Patients may present with a rapid clinical deterioration and hemodynamic instability. Physicians should be familiar with the practical management of this surgical emergency and the treatment options available.

Regional lymph node status after neoadjuvant chemoradiation of rectal cancer producing a complete or near complete rectal wall response.

AIM: Transanal excision of the tumour site after complete response to chemoradiotherapy can determine the rectal wall response to treatment. This study was designed to assess whether the absence of tumour in the rectal wall corresponds to the absence of tumour in the mesorectum (true pathological complete response). METHOD: A retrospective review identified patients who underwent preoperative chemoradiation therapy for advanced mid and low rectal cancer followed by routine pre-planned radical surgery with total mesorectal excision. Patients in whom the pathology specimen showed no residual tumour in the rectal wall (ypT0) or a ypT1 lesion were assessed for tumour involvement in the mesorectum. RESULTS: Seventy-eight patients who underwent pelvic chemoradiation followed by radical surgery were reviewed. The rectal wall tumour disappeared in eight (ypT0). Of these, residual tumour was found in the mesorectum (ypT0N1) in one (12%) patient. Eleven patients were found to have ypT1 residual tumour. Of these, two (18%) had a final post-surgical staging of ypT1N1. CONCLUSION: Complete rectal wall tumour eradication was achieved in 10% of the patients, and downstaging to ypT1 was achieved in 14%. In 15% (12% in ypT0 and 18% in ypT1) of these patients, residual tumour cells were evident in the mesorectum. This would probably have rendered these patients with residual disease had a nonradical approach of transanal excision of the original tumour site been employed. Caution should be taken when considering the avoidance of radical surgery.

The effect of ß-adrenergic blockade and COX-2 inhibition on healing of colon, muscle, and skin in rats undergoing colonic anastomosis.

OBJECTIVE: COX inhibitors and ß-adrenergic blockers were recently shown to reduce cancer progression in animal models through various mechanisms. These include the prevention of immune suppression during the critical perioperative period, and the preclusion of direct promoting effects of catecholamines and prostaglandins on malignant tissue growth. To assess the safety of such pharmacological treatments in the context of oncologic surgery, the current study evaluates wound healing efficacy in the skin, muscle, and colon tissues in rats undergoing colonic anastomosis. METHODS: F344 rats were treated daily with a COX-2 inhibitor (etodolac), a ß-adrenergic blocker (propranolol), both drugs or vehicles. All rats underwent skin punch biopsy, and half were also subjected to laparotomy and colonic anastomosis. Tensile strength of the abdominal wall and colonic bursting pressure were assessed on Days 3, 7, and 30 postoperatively, and skin biopsy site healing was scored on Days 2, 4, and 6 postoperatively. RESULTS: None of the drug treatments produced any deleterious effects along the expected course of tissue healing. On Day 30, colon bursting pressure showed an abnormal strengthening in animals undergoing anastomosis compared to non-operated animals, across all drug treatments. This abnormal strengthening was attenuated by etodolac. In the skin, surgery reduced healing rate, irrespective of drug treatments. CONCLUSIONS: Effective doses of etodolac and propranolol caused no negative effects on wound healing processes in rats. The apparent safety of such treatments, together with their potential clinical benefits, suggests the incorporation of these treatments in oncologic patients undergoing curative tumor resection.

Colorectal carcinoma in inflammatory bowel disease: a comparison between Crohn's and ulcerative colitis.

AIM: The study assessed the clinicopathological features and survival rates of inflammatory bowel disease (IBD) patients with colorectal carcinoma (CRC), which accounts for ∼ 15% of all IBD associated death. METHOD: The medical records of patients operated on for CRC in three institutions between 1992 and 2009 were reviewed, and those with Crohn's colitis (CC) and ulcerative colitis (UC) were identified. Data on age, gender, disease duration, colitis severity, surgical procedure, tumour stage and survival were retrieved. RESULTS: Fifty-three patients (40 UC and 13 CC, 27 men, mean age at operation 54 years) were found. All parameters were comparable between the groups. Mean disease duration before CRC was 22.7 years for UC and 16.6 years for CC patients (P = 0.04). CRC was diagnosed preoperatively in 43 (81%) patients. Twenty-eight patients had colon cancer, 23 had rectal cancer and two patients had more than one cancer. All malignancies were located in segments with colitis. Over one-half were diagnosed at an advanced stage (36% stage III; 17% stage IV). At a mean follow up of 56 ± 65 months, 60% were alive (54% disease free) and 40% were dead from cancer-related causes. The 5-year survival rate was 61% for the UC and 37% for the CC patients (P = NS). CONCLUSION: CRC in IBD patients is frequently diagnosed at an advanced stage, a factor that contributes to poor prognosis. The risk of CRC in CC patients is comparable to those with UC. Long-term surveillance is recommended for patients with long-standing CC and UC.

Ultrasonographic assessment of patients referred with chronic anal pain to a tertiary referral centre.

BACKGROUND: Chronic anal pain is relatively common as a presentation to specialist physicians and surgeons. Currently, it is regarded as a functional disorder upon the exclusion of occult intersphincteric sepsis. Our study assessed an unselected cohort of patients presenting with chronic previously undiagnosed anal pain using routine ultrasonography. METHODS: All patients referred to a tertiary gastroenterology service between January 2005 and January 2008 with a diagnosis of chronic anal pain (>3 months duration with no clinical anorectal signs) underwent endoanal and static and dynamic transperineal ultrasound to assess for the frequency and pattern of occult intersphincteric sepsis. RESULTS: Of 1,580 patients referred, there were 146 presenting with chronic anal pain as a main symptom. Of these, 37 (25.3%) had intersphincteric sepsis (ISS) diagnosed with ultrasound examination with 17 undergoing evaluable surgery. There was a male preponderance (70.3%) with the diagnosis being made in 46% of cases after 6 months of symptoms and with 80.8% having posteriorly located sepsis. This occurred on a background of 62% having previous acute proctological conditions. There was complete ultrasonographic and operative concordance with 15 becoming asymptomatic after surgery at a mean follow-up of 6 months. CONCLUSION: Occult intersphincteric sepsis is not uncommon and is diagnosed using routine ultrasonography at the time of clinical presentation. Endoanal and transperineal ultrasound is recommended as part of the investigative armamentarium to exclude categorization as functional anorectal pain. This is currently not part of the Rome III coding for such a diagnosis suggesting a revision of these diagnostic criteria for the ultimate diagnosis of functional proctalgia.

Laparoscopic colectomy for transverse colon carcinoma.

BACKGROUND: Laparoscopic resection of transverse colon carcinoma is technically demanding and was excluded from most of the large trials of laparoscopic colectomy. The aim of this study was to assess the safety, feasibility, and outcome of laparoscopic resection of carcinoma of the transverse colon. METHODS: A retrospective review was performed to identify patients who underwent laparoscopic resection of transverse colon carcinoma. These patients were compared to patients who had laparoscopic resection for right and sigmoid colon carcinoma. In addition, they were compared to a historical series of patients who underwent open resection for transverse colon cancer. RESULTS: A total of 22 patients underwent laparoscopic resection for transverse colon carcinoma. Sixty-eight patients operated for right colon cancer and 64 operated for sigmoid colon cancer served as comparison groups. Twenty-four patients were identified for the historical open group. Intraoperative complications occurred in 4.5% of patients with transverse colon cancer compared to 5.9% (P = 1.0) and 7.8% (P = 1.0) of patients with right and sigmoid colon cancer, respectively. The early postoperative complication rate was 45, 50 (P = 1.0), and 37.5% (P = 0.22) in the three groups, respectively. Conversion was required in 1 (5%) patient in the laparoscopic transverse colon group. The conversion rate and late complications were not significantly different in the three groups. There was no significant difference in the number of lymph nodes harvested in the laparoscopic and open groups. Operative time was significantly longer in the laparoscopic transverse colectomy group when compared to all other groups (P = 0.001, 0.008, and <0.001 compared to right, sigmoid, and open transverse colectomy, respectively). CONCLUSIONS: The results of laparoscopic colon resection for transverse colon carcinoma are comparable to the results of laparoscopic resection of right or sigmoid colon cancer and open resection of transverse colon carcinoma. These results suggest that laparoscopic resection of transverse colon carcinoma is safe and feasible.

Is stapled ileal pouch anal anastomosis a safe option in ulcerative colitis patients with dysplasia or cancer?

PURPOSE: The purpose of this study was to investigate the oncological and clinical outcome of ulcerative colitis (UC) patients with coexisting colorectal cancer/dysplasia following stapled ileal pouch-anal anastomosis (IPAA). MATERIALS AND METHODS: One hundred eighty-five UC patients who underwent stapled IPAA were followed prospectively in a comprehensive pouch clinic. They were divided into three groups: colorectal cancer, dysplasia, and no cancer/dysplasia. Demographic parameters, clinical data, and oncological and functional outcome of the three groups were compared. RESULTS: Sixteen patients had cancer and 14 had dysplasia. Two of the three cancer patients who developed metastatic disease died. One patient who had rectal cancer was found to have cancer cells in the rectal cuff 10 years after IPAA. All other cancer/dysplasia patients were disease-free at 62 months (median). The 5-year survival rate was 87.5% for the cancer group and 100% for the others (p < 0.0001). Chemotherapy (nine patients) did not affect pouch function. Two rectal cancer patients who received radiotherapy did not maintain a functioning pouch. Overall pouch failure rates were 19%, 7%, and 6% for cancer, dysplasia, and no-cancer/dysplasia patients, respectively (p = 0.13). The mean frequency of bowel movements in 24 h was similar between the groups. CONCLUSIONS: Stapled IPAA is a reasonable option for UC patients with cancer/dysplasia. Chemotherapy is safe, but the effect of radiation on pouch outcome is worrisome. Close long-term follow-up for UC patients with cancer/dysplasia is recommended for early detection of possible recurrence.

Multiple surgical interventions due to recurrent intussusception in a patient with henoch-schönlein purpura: a case report.

Gastrointestinal (GI) symptoms in Henoch-Schönlein purpura (HSP) are common and occur in about two-thirds of patients. Surgical complications, while uncommon, are potentially severe. The preoperative diagnosis is based mainly on a high index of suspicion leading to imaging studies that may include abdominal sonography. We describe here the first case of a patient who developed recurrent intussusception attributed to HSP that led to repeated surgical interventions.

Minimally invasive approach to colorectal surgery.

While the development of laparoscopic surgery over the last two decades was amazingly fast, its adoption was neither uniform nor universal. Some procedures, like laparoscopic cholecystectomy, rapidly became the standard of care throughout the surgical community. Laparoscopy for colorectal surgery gained much less acceptance. Factors such as technical complexity, cost, duration of surgery and concerns about oncologic safety influenced the hesitancy in performing this surgery, and it took the surgical community more than a decade to admit that the laparoscopic option is legitimate: it is safe, and it provides the patients with the advantages of minimally invasive surgery, without any surgical or oncologic compromise. This slow process of maturation had a significant advantage, as it allowed this kind of surgery to be thoroughly investigated. Its acceptance is now well based on multitude of data, available from many basic science and clinical studies. Not many procedures in the daily surgical practice are as evidence-based as is laparoscopic colon surgery. The aim of this review was to describe some general aspects of laparoscopic colorectal surgery, and examine the data supporting its use in different procedures for various pathologies, both benign and malignant.

Laparoscopically assisted reversal of Hartmann's procedure.

BACKGROUND: Restoration of bowel continuity after Hartmann's procedure is a major surgical procedure associated with substantial morbidity and occasional mortality. The authors review their experience with laparoscopically assisted reversal of Hartmann's procedure (LARH) to assess difficulties and potential advantages associated with this procedure. METHODS: A retrospective chart review of a prospectively entered database was performed to identify patients who underwent LARH over a period of 7 years. Data regarding demographic and clinical characteristics, surgical details, and postoperative course were reviewed. Specifically, age, gender, diagnosis at initial operation, American Society of Anesthesiology (ASA) score, comorbidities, operative time, conversion, surgical team, complications, postoperative bowel movements, and hospital stay were assessed. All surgeries were performed by six experienced laparoscopic surgeons. RESULTS: A total of 27 patients, 17 men and 10 women, with mean ages of 58.1 and 62.9 years, respectively, underwent LARH. The procedure was laparoscopically completed for 23 patients. Conversion to laparotomy was required for four patients (14.8%) because of dense adhesions after the initial Hartmann's procedure in three patients and rectal perforation in one patient. The median operative time was 226 min, and the median hospital stay was 6 days. The overall morbidity rate was 33% (9 patients), attributable to colostomy site infection in 5 of the 9 patients. One patient required reoperation because of intraabdominal bleeding. No anastomotic leaks or intraabdominal abscesses were recorded. There was no operative mortality. CONCLUSIONS: Laparoscopically assisted reversal of Hartmann's procedure is technically challenging and time consuming. However, in the hands of experienced laparoscopic surgeons, it is safe and associated with a reasonably low conversion rate. Furthermore, the relatively low morbidity rate, short hospital stay, and earlier return of bowel function may be beneficial to patients.

Is mechanical bowel preparation mandatory for left-sided colonic anastomosis? Results of a prospective randomized trial.

BACKGROUND: Preoperative mechanical bowel preparation is aimed to reduce the risk of infectious complications, and its utility is a dogma in left-sided large bowel anastomosis. The aim of this study was to specifically assess whether colocolonic and colorectal anastomoses may be safely performed without preoperative mechanical bowel preparation. METHODS: Patients undergoing elective colon and rectal surgery with primary colocolonic or colorectal anastomosis were prospectively randomized into two groups. The "prep" group had mechanical bowel preparation prior to surgery, while the "non-prep" group had surgery without pre-operative mechanical bowel preparation. RESULTS: Two hundred forty-nine patients were included in the study, 120 in the prep group and 129 in the nonprep group. Demographic characteristics, indications for surgery, and type of surgical procedure did not significantly differ between the two groups. There was no difference in the rate of surgical infectious complications between the two groups. Overall infectious complication rate was 12.5% in the prep group and 13.2% in the non-prep group. Wound infection, anastomotic leak, and intra-abdominal abscess occurred in 6.6%, 4.2%, and 1.6% of patients in the prep group and in 10.0%, 2.3%, and 0.7% of patients in the nonprep group, respectively (p=NS). CONCLUSIONS: These results suggest that elective left-sided anastomosis may be safely performed without mechanical preparation. Multicenter studies to test the reproducibility of these results are required, to support a change in this time-honored practice.

Pre-eclampsia is associated with sleep-disordered breathing and endothelial dysfunction.

Pre-eclamptic toxaemia (PET) may be associated with both endothelial dysfunction (ED) and sleep-disordered breathing (SDB). It was hypothesised that females with PET would demonstrate both SDB and ED, and that a correlation between these two would suggest a potential causative association. A total of 17 females with PET and 25 matched females with uncomplicated pregnancy were studied. They underwent a nocturnal ambulatory sleep study (using Watch_PAT100) and noninvasive evaluation of endothelial function utilising the reactive hyperaemia test (using Endo_PAT 2000). A higher ratio of post- to pre-occlusion pulse-wave amplitude (endothelial function index (EFI)) indicated better endothelial function. Females with PET had a significantly higher respiratory disturbance index (RDI) and lower EFI than controls (18.4+/-8.4 versus 8.3+/-1.3.h(-1), and 1.5+/-0.1 versus 1.8+/-0.1, respectively). Blood pressure significantly correlated with RDI and with EFI. EFI tended to correlate with RDI. In conclusion, these results suggest that both sleep-disordered breathing and endothelial dysfunction are more likely to occur in females with pre-eclamptic toxaemia than in females with uncomplicated pregnancies. The current authors speculate that respiratory disturbances contribute to the functional abnormality of the blood vessels seen in females with pre-eclamptic toxaemia, although causality cannot be determined based on this study.

Risk factors regarding the need for a second operation in patients with Crohn's disease.

BACKGROUND/AIMS: The majority of Crohn's disease patients undergo surgery. However, the factors that predict post-operative recurrence remain controversial. The aim of the present study was to shed light on the potential predictors of such recurrence. METHODS: 86 patients who underwent operative procedures for Crohn's disease were retrospectively studied. Recurrence was defined as the need for a second operation. Life table and multivariate analysis were performed to find the predictors of recurrence. RESULTS: In 26/86 (30%) of the patients, post-operative recurrence was diagnosed within a mean of 42 months of the follow-up. Logistic regression analysis revealed that smoking (OR 3.69, 95% CI 2.06-11.52) and perforating disease (OR 4.09, 95% CI 1.31-12.65) were associated with a risk of recurrence. However, survival analysis showed that only perforating disease was associated with an early post-operative recurrence (log-rank test, p < 0.001). Neither resected surgical specimen characteristics, nor the duration and the location of the disease were found to predict the need for a second operation. CONCLUSION: The risk for Crohn's disease patients who undergo surgery is related to the presence of perforating disease and smoking, which predict the need for a second operation. The former is associated with an even earlier recurrence.