Anal pathology in patients with Crohn's disease

BACKGROUND

A distinctive feature of patients suffering from Crohn's disease is a predisposition to develop a variety of anal complications. The aetiology of such conditions is unclear, and the reported incidence of anal involvement in Crohn's disease varies party due to the various criteria used for classification. This study aims to review the management of patients with symptomatic anal pathology associated with Crohn's disease at St Vincent's Hospital, Melbourne.

METHODS

A database of 306 patients with Crohn's disease referred to the department between January 1978 and October 1994 was reviewed to identify those patients with symptomatic anal disease. The anal pathology was recorded and classified. Demographic data and the clinical and surgery history of the patient were recorded.

RESULTS

Of the 306 patients with Crohn's disease, 129 (42.4%) were identified as having symptomatic anal pathology. Patients were likely to present with anal symptoms after they had been diagnosed as having intestinal Crohn's disease (46.1%). The commonest presentations were perianal abscess (29.5%), anal fissure (27.6%), and low anal fistula (26.7%). A minority of patients presented with high/complex anal fistulae (3.8%), or recto-vaginal fistulae (5.2%). Five per cent of patients had Crohn's disease localized to the anal area. The pattern of intestinal disease in the remaining patients was small bowel 21.1%. small bowel and colon 31.9%, and colon 43.0%. A total of 244 local anal and surgical procedures were performed on these patients; the commonest of these were drainage of an abscess (38.5%), examination under anaesthetic (29.1%), and laying open of a low anal fistula (22.5%). Following surgical treatment, the recurrence rate for perianal abscesses was 13%, and for low anal fistulae 6%.

CONCLUSIONS

The majority of patients with Crohn's disease who develop anal pathology have an excellent prognosis. A minority of patients develop complex anal complex anal fistulae and these remain a therapeutic challenge.

Intestinal haemorrhage after strictureplasty for Crohn's disease

Between 1978 and 1995, a total of 52 patients have undergone 241 small intestinal strictureplasties at 76 operations in one surgical unit. The post-operative course was complicated by intestinal haemorrhage in 4 patients. In 3, the bleeding settled with conservative management. The 4th patient required laparotomy on two occasions to control bleeding from duodenal Crohn's disease and the proximal jejunal strictureplasty site, respectively. Strictureplasty is a relatively safe operation, but has a low incidence of potentially life-threatening post-operative haemorrhage.

Total laparoscopic proctocolectomy and laparoscopy-assisted proctocolectomy for inflammatory bowel disease: operative technique and preliminary report

We present the operative technique of laparoscopic proctocolectomy along with the clinical course of the first four patients to undergo this procedure. The operation was conducted through five 12-mm ports. In total laparoscopic proctocolectomy, the dissection began with the sigmoid, left colon, and rectum. The gastrocolic ligament was opened at the level of the midtransverse colon and dissected along with the transverse mesocolon toward the splenic flexure. The attachments and vessels of the right side of the gastrocolic ligament and the right colon were taken last. This sequence was followed because gradual mobilization of the colon displaced all structures in the middle of the abdomen and obscured vision. The specimen was extracted through the anus. In laparoscopy-assisted proctocolectomy, it was necessary to incise only the white line of Toldt of the ascending and descending colon, mobilize the hepatic and splenic flexures, and ligate the vessels of the gastrocolic ligament. Then the vessels of the mesentery were ligated near the bowel wall through a 6.5-cm midline subumbilical incision from which the abdominal colon was also extracted. The rectum was then completely dissected and sectioned at 10-15 cm from the anus, everted, and resected at the dentate line. Mean operative time was 7 h, 18 min, and average blood loss was 493 ml. One patient had urinary retention. Return to liquid diet took a mean of 4 days. Average postoperative stay, which depended on full return of bladder function and teaching of stoma care, was 10 days.

Experience with ileostomy and colostomy in Crohn's disease

This study involved 746 patients with Crohn's disease treated surgically within a 13-year interval in whom 227 stomas (159 primary, 68 secondary) were created. The main indication (64 per cent) for primary stoma was severe perianal or genital fistulous disease. Revisional surgery for stomal complications was more common following colostomy than ileostomy (31 versus 5 per cent, P < 0.01). Twenty years after the first symptoms of Crohn's disease the cumulative risks of receiving any stoma or a permanent stoma were 41 and 14 per cent respectively. Four parameters were shown by proportional hazards analysis to be independently associated with the risk for any stoma as well as a permanent one; increased risk coincided with rectal inflammation, perianal fistula or abscess, and absence of small intestinal involvement. In addition, long-standing symptomatic disease before the first surgical intervention reduced the risk of a permanent stoma. The long-term chances of closure following temporary stoma were 75 per cent when used for anastomotic protection or avoidance, 79 per cent after postoperative complications, and 40 per cent for perianal or genital fistulas or for rectal inflammation or stenosis. Rectal disease and perianal fistula were the only independent predictors of a low possibility of stoma closure during follow-up.

The role of small bowel radiology in the diagnosis and management of Crohn's disease

A total of 50 children with Crohn's disease were examined by barium follow-through and colonoscopy with ileoscopy, to determine the value of small bowel radiology. Of these children, 40 (80%) had evidence of small bowel Crohn's disease on ileoscopy and/or barium follow-through. Twenty-two (44%) had disease confined to the terminal ileum. Radiology diagnosed disease proximal to the terminal ileum in 18 cases (36%), including 5 children in whom the terminal ileum was normal. Ileoscopy was not possible in nine patients (18%), six of whom had small bowel disease on barium follow-through. Colonic involvement, demonstrated in 34 (68%), was the sole site of disease in 6 (12%). Fifteen (30%) children had surgery, which in six (12%) was determined by the radiological findings of complicated small bowel disease. As the terminal ileum may be uninvolved in the presence of proximal ileal disease, normal ileoscopy does not exclude small bowel Crohn's disease. Small bowel radiology remains necessary to assess the full extent of Crohn's disease in children.

Natural history of strictureplasty in Crohn's disease: 9-year experience

OBJECTIVE

To study the short- and long-term outcomes in patients with Crohn's disease who have undergone strictureplasty.

DESIGN

A retrospective review with a prospective follow-up (mean 54.4 months [range from 4 to 108 months]).

SETTING

The Inflammatory Bowel Disease Centre at Mount Sinai Hospital in Toronto.

PATIENTS

Forty-three patients (29 men, 14 women) who underwent 154 strictureplasties for Crohn's disease. The mean age of the patients was 32.5 years (range from 17 to 55 years).

INTERVENTION

Strictureplasty by either the Heineke-Mikulicz (145 strictureplasties) or the Finney (9 strictureplasties) technique in the duodenum, small intestine and at the site of the previous anastomosis.

MAIN OUTCOME MEASURES

Factors studied for symptomatic recurrence included the type of procedure previously performed, the type of strictureplasty, the number of previous operations and the site of the disease.

RESULTS

There were no deaths. There was one documented leak. Twenty-six patients remained symptom free during the follow-up period. Fourteen patients required reoperation for progressive obstructive disease. None of the differences in the variables studied was statistically significant when related to the symptomatic recurrence rate. However, only 2 of 11 patients who had strictureplasty as the only procedure have required reoperation.

CONCLUSIONS

Strictureplasty is a safe and useful procedure in the management of extensive obstructive Crohn's disease. Strictureplasty does not seem to alter the natural history of the disease.

Strictureplasty for Crohn's disease in Japan

Strictureplasty has recently been advocated in the treatment of obstructive strictures of the small bowel in patients with Crohn's disease. In this group study, results for 69 patients with Crohn's disease who underwent strictureplasty were analyzed by sending questionnaires to 13 institutions belonging to the Research Committee of Inflammatory Bowel Disease of the Japanese Ministry of Health and Welfare. No mortality and anastomotic leakage were observed. Strictureplasties of both the Heineke-Mikulicz and Finney varieties were considered to be safe procedures, even though the sutures had to be applied at the slightly inflammed site. The median follow up was 37 months (range, 0-133 months), and 12 patients needed reoperation. The cumulative 3-year operation-free rate was 92.5% and the 5-year rate was 70.3%. The site of the lesion, the strictureplasty procedure, and previous history of small bowel resection did not significantly influence the operation-free intervals. The cumulative 5-year operation-free rate of the group treated with home elemental enteral nutrition (83.3%) was better than that of the non-treated group (65.3%). Strictureplasty was found to be a safe and effective surgical procedure for high-risk patients with Crohn's disease in whom an appropriate length of bowel should be saved.

Strictureplasty for Crohn's disease of small intestine. Present status in Western countries

The concept of a minimal operation for Crohn's disease, particularly of the small intestine, is based on the rationale that it is impossible to cure Crohn's disease by excision, since it is a panintestinal disease that can eventually occur in any part of the remaining intestine. The surgeon is required to treat only the complications and to conserve as much intestine as possible. In the case of stricture, excision is not necessary if the narrowing can be corrected. Strictureplasty is ideal for short strictures of the small intestine in quiescent disease. The morbidity and mortality of strictureplasties are low in. In spite of leaving the "burnout" disease behind, the recurrent stricture after strictureplasties is comparable to the recurrence after bowel resections. The purpose of strictureplasty is to correct the small bowel obstruction and to preserve the length of the small intestine. It is, however, not intended to replace a small bowel resection.

Recurrence and reoperation after strictureplasty for obstructive Crohn's disease: long-term results [corrected]

Strictureplasty extends the surgical options for the treatment of obstructive Crohn's disease. Over 15 years, 52 patients had 241 strictureplasties at 76 operations with no operative mortality and with septic complications in only two patients (4 percent). Median (range) follow-up was 49.5 (1-182) months. Nineteen patients (36 percent) required a second operation for Crohn's disease between 1 and 57 months after first strictureplasty. Most symptomatic recurrence was caused by new segments of stricturing or perforating disease, and recurrence of Crohn's disease was noted at only nine strictureplasty sites (3.7 percent) in four patients. Seven patients (13 percent) required a third operation for Crohn's disease. Patients undergoing strictureplasty alone were no more likely to require reoperation than those who had a concomitant resection at the first procedure (X2 = 0.619, P > 0.2). The reoperation rates after first and second operations were similar (X2 = 0.021, P > 0.2). Minimal surgery does not appear to lead to an accelerated or additional need for subsequent operation. Strictureplasty provides a safe, effective and rapid procedure to restore patients to good health while preserving the intestine and may be recommended for carefully selected strictures as an adjunct to conventional excisional surgical treatment.

Surgery for Crohn's anal fistulas

The aim of this study was to analyze the features of Crohn's anal fistulas and to evaluate the efficacy of seton treatment. In 119 patients with Crohn's disease, the incidence of anal fistula was 56% (67/119), with no significant difference in the incidence among patients with ileitis, colitis, and ileocolitis. "Intractable" anal fistulas were found in 17% of patients with ileitis, compared to 64% of those with colitis (P = 0.051) and 68% of those with ileocolitis (P = 0.014). Seton treatment, i.e., non-cutting, long-term seton drainage, was performed for 21 patients (5 with intersphincteric, and 16 with transsphincteric fistulas). In the 16-month follow up, 9 patients required redrainage for recurrent fistulous abscess, mainly because of progressive colorectal disease. Finally, a good result was obtained in 17 of the 21 patients (81%) and no recurrent fistulous abscess developed in the 8 patients in whom all setons were removed. Anal continence was preserved in all the patients. These results indicate that anal fistulas with Crohn's ileitis were cured more easily than those with colitis or ileocolitis, and that seton treatment was effective for intersphincteric fistula with multiple fistula openings and for transphincteric fistulas in patients exhibiting remission of intestinal Crohn's disease.

Remaining small bowel endoscopic lesions at surgery have no influence on early anastomotic recurrences in Crohn's disease

OBJECTIVES

We recently demonstrated that 65% of patients operated on for Crohn's disease (CD) had lesions of the small bowel at perioperative endoscopy (POE). These lesions were unrecognized before surgery in more than half of the patients. The aim of this study was to assess the prognostic value of endoscopic small bowel lesions let in place at time of surgery on further anastomotic endoscopic relapse.

METHODS

Twenty one patients (10 women, 11 men, mean age 34 yr) had an enteroscopy from the terminal ileum to the ligament of Treitz during an ileocolectomy performed for CD. All patients were subsequently enrolled in a placebo-controlled trial of mesalazine for the prevention of early endoscopic relapse; 10 patients received placebo, and 11 received mesalazine (1.5 g/day) for 12 wk after surgery. At the end of this trial, they all had a colonoscopy with inspection of the anastomosis and the neoterminal ileum.

RESULTS

POE was completed up to the angle of Treitz in all 21 patients. In 10/21 cases (47%), mild lesions were found distributed at random along the small intestine 30 cm beyond the resection margin. At colonoscopy performed 12 wk later, lesions were found in 11/21 cases (52%) between section margin and were estimated to be 25 cm over the anastomosis. Endoscopic recurrence occurred in 5/10 patients who received placebo and 6/11 patients who received mesalazine. Endoscopic recurrence occurred in 5/10 patients having lesions at POE and in 6/11 patients who had no lesions. There was no relationship between endoscopic recurrence at 12 wk and presence of lesions at initial POE, whatever the postoperative treatment.

CONCLUSION

Endoscopic lesions let in place after "curative" surgery have no influence on early endoscopic anastomotic recurrences in CD.

Long-term follow-up study of Crohn's disease in Japan. The Research Committee of Inflammatory Bowel Disease in Japan

Two hundred and three patients with Crohn's disease seen at Kyushu University, Fukuoka University, and their affiliated centers from 1973 to 1988 were followed for 4.4 +/- 3.2 years (mean +/- SD), to evaluate the prognosis relative to life span and surgery. Cumulative survival rate and cumulative operation rate were calculated by the life table method. Cumulative survival rates 5 and 10 years after diagnosis were 98.9% and 98.9%, respectively; these figures were not different from the expected survival rates in the sex-and age-matched general population. Cumulative operation rates 5 and 10 years after the onset of symptoms were 16.2% and 39.1%, respectively, In a second study, we investigated 419 patients with Crohn's disease, diagnosed at nine institutions from 1975 to 1990. The follow-up period was 6.3 +/- 3.9 years and the information was obtained from mailed questionnaires. Cumulative survival rates 5 and 10 years after diagnosis were 99.2% and 96.9%, respectively. Cumulative operation rates 5 and 10 years after the onset of symptoms were 30.3% and 70.8%, respectively. These results indicate that the prognosis of Japanese patients with Crohn's disease may be superior to that reported in Western countries.

Functional results of the double-stapled ileoanal reservoir

BACKGROUND

The preferred method for creation of an ileoanal reservoir is still controversial. We prospectively studied the functional and physiologic outcome of our patients who underwent a double-stapled ileoanal reservoir (DSIAR).

STUDY DESIGN

All consecutive patients who underwent restorative proctocolectomy with a DSIAR between 1988 and 1993 were evaluated. Functional results were assessed by questionnaires and anal manometry preoperatively and two, 12, and 24 months postoperatively.

RESULTS

One hundred forty patients (90 males and 50 females) with a mean age of 40.7 (range, 12 to 71) years were evaluated. Of these, 107 patients (77 percent) had ulcerative colitis, 21 (15 percent) had familial adenomatous polyposis, six (4 percent) had indeterminate colitis, and six (4 percent) had a post-operative diagnosis of Crohn's disease. One hundred twenty-four (95 percent) of the 131 patients with closed stomas were available for functional and manometric evaluation at a mean follow-up period of 24 months. A 32 percent decline in the mean resting pressure (from 71.3 +/- 4 to 48.2 +/- 3.4 mm Hg) occurred early after DSIAR (p < 0.001) with partial recovery by 24 months. The maximal internal sphincter resting pressure showed a 39 percent decline (from 90.8 +/- 4.9 to 55.3 +/- 5.7 mm Hg, p < 0.005) with recovery after 12 months. There were no significant changes in the length of the high-pressure zone or mean or maximal squeeze pressures. A mean of 5.4 (two to 13) bowel movements occurred during the day and a mean of 1.2 (zero to four) occurred at night. Perfect or almost perfect continence was reported during the day and night, respectively, by 95 and 92 percent of the patients. Overall perioperative complications occurred in 30 patients (21 percent) including septic complications in eight (6 percent), and pouchitis in eight (6 percent). There was one postoperative death (0.7 percent).

CONCLUSIONS

Double-stapled ileoanal reservoir is associated with good subjective functional and objective physiologic results and has acceptable rates of morbidity and mortality.

Clinical course of perianal fistulas in Crohn's disease

The clinical course of perianal fistulas and associated abscesses was evaluated prospectively in 90 patients with Crohn's disease. Fistula type, rectal disease, faecal diversion, and immunosuppression were examined as prognostic indicators for fistula healing and recurrence. Median follow up was 22 months. The outcome was evaluated with life table analysis. Prognostic factors were analysed by multiple regression. Inactivation was achieved in all patients. The risks of recurrent fistula activity were 48% at one year and 59% at two years. Fistulas were healed in 51% after two years but reopened in 44% within 18 months of healing. Faecal diversion and absence of rectal disease decreased recurrence rates (p = 0.019/0.04) and increased healing rates (p = 0.005/0.017). The outcome in patients with trans-sphincteric fistulas was better than that in those with ischiorectal fistulas but worse than in patients with subcutaneous fistulas (p = 0.015 for healing; p = 0.007 for recurrent fistula activity). After initial treatment about 20% of the patients were symptomatic and about 10% had painful events per six month period. Incontinence was rare and did not increase during the study period. Perianal fistulas and associated abscesses can be controlled safely by simple drainage of pus collections. Frequent reinfection and re-opening after healing of fistulas are characteristic. Fistula type, rectal disease, and stool contamination influence the clinical course. Only a few patients, however, have continuous symptoms from perianal fistulas.

Adult patients with a short bowel due to Crohn's disease often start with a short normal bowel

OBJECTIVE

The normal adult human small intestinal length, measured surgically or at autopsy from the duodeno-jejunal flexure, ranges from 275 to 850 cm. The length is generally shorter in women than in men. Patients with a short bowel have often had relatively little bowel resected and the majority of patients are women. We aimed to determine whether patients with a short bowel had a short small intestinal length before any resections.

PATIENTS AND METHODS

In 11 patients (six men and five women) with Crohn's disease and less than 200 cm residual small intestine, both the residual length of small intestine and the amount resected were measured.

RESULTS

Patients had a median of four resections (range 1-5). The median length of small bowel resected was 120 cm (range 60-165 cm) and the medium length of small bowel remaining was 125 cm (range 90-185 cm). Thus, the calculated median original small intestinal length was 240 cm (range 205-315 cm).

CONCLUSION

Although there may have been some bowel shortening as a result of Crohn's disease, the original small intestinal length before any resections was short. It is therefore more important, after performing a bowel resection, to measure the remaining than the resected bowel length. Patients with Crohn's disease and a short bowel may have had a short but 'normal' small intestinal length before any bowel was resected.

[Crohn's disease and intestinal carcinoma: presentation of 2 cases and review of the literature]

We present the cases of two patients with Crohn's disease with consequent adenocarcinoma of the bowel. The first patient underwent an ileo-colic bypass 23 years before, a mucinous adenocarcinoma (Duke's stage C) was found on the anastomotic tract and on the excluded bowel, in areas within histologically recognizable Crohn's disease. In the second patient both the adenocarcinoma (Duke's stage C) of the transverse colon and the Crohn's disease (without any clinical evidence) in active phase has been found at the same time. We underline that such association seems to be not so rare as it seemed in the past. Accurate observation of patients, long time sufferers from the Crohn's disease, is advised to single out possible neoplastic complications at an early stage.

A surgical subspecialist enhances general surgical operative experience

OBJECTIVE

To examine the impact of a surgical subspecialist on residents' operative experience in a mature general surgery training program.

METHODS

American Board of Surgery operative experience records were used to examine the impact of a surgical subspecialist on surgical training in a stable residency program. Operations performed as surgeon by residents in their chief and junior years were analyzed 4 years before and 4 years after the addition of this subspecialist to the faculty. Hospital admissions for Crohn's disease and ulcerative colitis during these periods were analyzed as well.

RESULTS

There was a statistically significant increase in the number of ileal pouch anal anastomoses, ileostomies, small-bowel resections, partial colectomies, and coloanal anastomoses performed by surgical residents after the addition of a colorectal surgical subspecialist.

CONCLUSIONS

Subspecialty faculty may favorably influence general surgical training by increasing resident operative experience and patient management skills with procedures characteristic of the subspecialty.

Inflammatory bowel disease in children

Inflammatory bowel disease remains a serious chronic illness in children. Recent developments in the care of these patients involves both basic science research into the pathophysiology of ulcerative colitis and Crohn's disease and the development of refinements in the surgical techniques and medical therapies available as treatment options. In Crohn's disease, a new steroid analogue (budesonide) shows some promise as a possible medical treatment that would limit the devastating side effects of steroids in children. In addition, the bowel-sparing technique of strictureplasty has now been reported in children with good results. In ulcerative colitis, the surgical technique of endorectal pull-through continues to evolve with reports of the efficacy of specific pouch designs and surgical techniques. An understanding of pouchitis, the most common complication of endorectal pull-through, has focused on documenting specific alterations in the microbiology and physiology of the pouch, as well as investigating a possible link between autoantibodies and susceptibility to this complication.