Disappointing results following proctectomy with end-colostomy for anorectal Crohn's disease.

I read with interest the article by de Buck van Overstraeten et al., ‘Intersphincteric proctectomy with end-colostomy for anorectal Crohn's disease (CD) results in early and severe proximal colonic recurrence’.1 In their case series, 10 consecutive patients underwent intersphincteric proctectomy with end-colostomy. Early symptomatic recurrence occurred in 9 of the 10 patients at a median follow-up of 9.5 months. Completion colectomy with end-ileostomy was performed in 5 patients. One patient, who underwent a second segmental colectomy with a new end-colostomy, showed again endoscopic recurrence requiring surgery despite anti-TNF-α treatment. Based on these results, the authors recommend a proctocolectomy with end-ileostomy for anorectal CD. These results are quite impressive to me. I believe that following bowel resection for CD, recurrence in the proximal part of the stoma is not common, although recurrence in the proximal site of the anastomosis is common.2 Before the era of biologics, extensive active colitis was common in patients with anorectal CD probably because colonic disease was not under control with conventionalmedical treatment. Therefore,many patients underwent proctocolectomy with end-ileostomy for severe anorectal CD.3 In my research in Birmingham, 103 patients who underwent single-stage proctocolectomy with end-ileostomy for CDwere reviewed.3 The reoperation rate for small bowel recurrence was quite low; 13% at 5 years, 17% at 10 years and 25% at 15 years after surgery. The most common site of recurrence was the distal ileum within 25 cm of the ileostomy. In the present study,1 all patients except one were taking immunosuppressant or anti-TNF-α agents before surgery. Although only 2 patients showedmild colitis at ileocolonoscopy, all other patients had no signs of colitis. Under these conditions, all patients underwent proctectomy with end-colostomy for anorectal CD. In all but one patient, medications with antiTNF-α agents or immunomodulators were restarted after surgery. We do not know why many patients developed severe colitis after proctectomy with end-colostomy despite these medications. However, I have recently had similar experiences. After defunctioning colostomy for severe anorectal CD, several