The prognosis of ileorectal anastomosis in Crohn's disease

Ileorectal anastomosis in patients with Crohn's disease. Postoperative complications and functional outcome-a systematic review

AIM

The objective of this systematic review was to investigate the outcomes of ileorectal anastomosis (IRA) in Crohn's disease and to clarify whether there are any time-related trends in outcome measures. The primary outcomes are risk of anastomotic leakage, death, clinical recurrence and subsequent diverting or permanent stoma and/or proctectomy. Secondary end-points are quality of life and functional outcome.

METHODS

Systematic searches were conducted using the Cochrane Library, Embase and MEDLINE. The complete search strategy is uploaded online at http://www.crd.york.ac.uk/prospero/. Human studies in English with over five subjects were included and no limit was set regarding the date of publication. All relevant studies were screened by two reviewers. The web-based software platform www.covidence.org was used for primary screening of the title, abstract, full-text review and data extraction.

RESULTS

The search identified 2231 unique articles. After the screening process, 37 remained. Key results were an overall anastomotic leak rate of 6.4%; cumulative rates of clinical recurrence of 43% and 67% at 5 and 10 years, respectively; an overall rate of proctectomy of 18.9%; and subsequent ileostomy required in 18.8%. Only one study presented useful data on quality of life. Recurrence rates remained stable over time. A small decline in the anastomotic leak rate was found.

CONCLUSIONS

Only minor improvements in the outcomes of IRA in patients with Crohn´s disease have occurred during the past 50 years regarding anastomotic leakage and recurrence, except for a slight increase in the rate of a functioning IRA. These results call for implementation guidelines in patient selection for IRA and postoperative medical treatment and follow-up.

Long term remission after ileorectal anastomosis in Crohn's colitis

BACKGROUND

Crohn's disease represents a heterogeneous entity, but its location tends to be relatively stable overtime. For extensive refractory Crohn's colitis, ileorectal anastomosis after colectomy is an engaging option, since the necessity of a permanent ileostomy is avoided.

AIMS

In our study, the long-term outcome of two groups of patients with Crohn's colitis who underwent colectomy and ileorectal anastomosis was compared. The first group had isolated colonic Crohn's disease without rectal involvement and perianal disease, while the second group included patients who had rectal and/or ileal involvement, with or without perianal disease.

METHODS

Between 1996 and 2016, in a single IBD tertiary center, 80 patients with a history of colectomy and ileorectal anastomosis for refractory Crohn's colitis were retrospectively identified.

RESULTS

Recurrence of disease was diagnosed in 57/64 of patients with Crohn's colitis with rectal and/or ileal and/or perianal involvement compared with 1/16 of patients with isolated Crohn's colitis without rectal and perianal disease in a median time of recurrence of 2 years (IQR 1-6 years, minimum to maximum, 1-18 years, p < 0.001). Only 6 patients (7,5%) underwent definitive end ileostomy without proctectomy (1 in the noIRP group and 5 in the IRP group).

CONCLUSION

Our data suggest that colectomy with ileorectal anastomosis may represent a curative option in patients with refractory isolated colitis without rectal and perianal involvement.

Surgery for luminal Crohn’s disease

Many patients with Crohn’s disease (CD) require surgery. Indications for surgery include failure of medical treatment, bowel obstruction, fistula or abscess formation. The most common surgical procedure is resection. In jejunoileal CD, strictureplasty is an accepted surgical technique that relieves the obstructive symptoms, while preserving intestinal length and avoiding the development of short bowel syndrome. However, the role of strictureplasty in duodenal and colonic diseases remains controversial. In extensive colitis, after total colectomy with ileorectal anastomosis (IRA), the recurrence rates and functional outcomes are reasonable. For patients with extensive colitis and rectal involvement, total colectomy and end-ileostomy is safe and effective; however, a few patients can have subsequent IRA, and half of the patients will require proctectomy later. Proctocolectomy is associated with a high incidence of delayed perineal wound healing, but it carries a low recurrence rate. Patients undergoing proctocolectomy with ileal pouch-anal anastomosis had poor functional outcomes and high failure rates. Laparoscopic surgery has been introduced as a minimal invasive procedure. Patients who undergo laparoscopic surgery have a more rapid recovery of bowel function and a shorter hospital stay. The morbidity also is lower, and the rate of disease recurrence is similar compared with open procedures.

MR colonography for the assessment of colonic anastomoses

PURPOSE

To assess colonic anastomoses in patients after surgical treatment by means of MR colonography (MRC) in comparison with conventional colonoscopy (CC).

MATERIALS AND METHODS

A total of 39 patients who had previously undergone colonic resection and end-to-end-anastomosis were included in the study. MRI was based on a dark-lumen approach. Contrast-enhanced T1-weighted (T1w) three-dimensional (3D) images were collected following the rectal administration of water for colonic distension. The MRC data were evaluated by two radiologists. The criteria employed to evaluate the anastomoses included bowel wall thickening and increased contrast uptake in this region. Furthermore, all other colonic segments were assessed for the presence of pathologies.

RESULTS

In 23 and 20 patients the anastomosis was rated to be normal by MRC and CC, respectively. In three patients CC revealed a slight inflammation of the anastomosis that was missed by MRI. A moderate stenosis of the anastomosis without inflammation was detected by MRC in five patients, which was confirmed by CC. In the remaining 11 patients a relevant pathology of the anastomosis was diagnosed by both MRC and CC. Recurrent tumor was diagnosed in two patients with a history of colorectal carcinoma. In the other nine patients inflammation of the anastomosis was seen in seven with Crohn's disease (CD) and two with ulcerative colitis. MRC did not yield any false-positive findings, resulting in an overall sensitivity/specificity for the assessment of the anastomosis of 84%/100%.

CONCLUSION

MRC represents a promising alternative to CC for the assessment of colonic anastomoses in patients with previous colonic resection.

Long-term outcome of surgically treated Crohn's colitis: a prospective study

PURPOSE

Although bowel-sparing techniques have been published for treatment of Crohn's disease of the small bowel because of its relentless nature, extent of resection in Crohn's colitis is still a topic of debate. This study was designed to prospectively evaluate the long-term outcomes of patients with isolated Crohn's colitis to identify patients that may benefit from initial more aggressive resection.

METHODS

We identified 179 patients with Crohn's disease operated on for primary colonic disease. They were divided into segmental colectomy, total abdominal colectomy, and total proctocolectomy groups, based on their initial operation. They were further characterized by extent and location of colonic involvement. Long-term outcome variables evaluated included colonic and small-bowel surgical recurrences, postoperative complications and long-term sequelae, long-term need for medical therapy, and need for permanent fecal diversion.

RESULTS

Fifty-five patients underwent segmental colectomy, 49 total abdominal colectomy, and 75 total proctocolectomy. Patients with diffuse colonic involvement were significantly less likely to undergo segmental colectomy than total abdominal colectomy (P < 0.0001) or total proctocolectomy (P < 0.0001). Patients with distal involvement or pancolitis were significantly less likely to undergo segmental colectomy than total abdominal colectomy (P < 0.0001) or total proctocolectomy (P < 0.0001). Overall there were 31 patients (24.4 percent) with surgical Crohn's recurrences during follow-up: 19 (38.8 percent) in the segmental colectomy, 8 (22.9 percent) in the total abdominal colectomy, and 4 (9.3 percent) in the total proctocolectomy group. There was a significant difference in time to recurrence between the three groups by log-rank test (P = 0.017). Segmental colectomy patients had a significantly shorter time to first recurrence than total proctocolectomy patients (P = 0.014). After adjusting for extent of disease, the segmental colectomy group had a significantly greater risk of surgical recurrence than the total proctocolectomy group (P = 0.006). Total proctocolectomy patients were significantly less likely to be still taking medications one year after the index operation than total abdominal colectomy patients (P = 0.003) and segmental colectomy patients (P = 0.0003). During follow-up, patients with isolated distal disease were significantly more likely to require a permanent stoma than patients with isolated proximal disease (P = 0.004).

CONCLUSIONS

A more aggressive approach should be considered in patients with diffuse and distal Crohn's colitis. Total proctocolectomy in the properly selected patients is associated with low morbidity, lower risk of recurrence, and longer time to recurrence. Patients after total proctocolectomy are more likely to be weaned off all Crohn's-related medications. Long-term rate of permanent fecal diversion is significantly higher in patients with distal disease.

Crohn's colitis: experience with segmental resections; results in a series of 84 patients

BACKGROUND

Colonic Crohn's disease can be treated surgically by total colonic resection or by segmental colonic resection. The aim of this study was to analyze the outcomes of patients treated by segmental colectomy for colonic Crohn's disease.

STUDY DESIGN

Among 413 patients undergoing operations for Crohn's disease, 84 had a segmental colectomy (cases of terminal ileitis with limited cecal involvement were not included). Postoperative complications, mortality, recurrence, and functional results were studied.

RESULTS

Eighty-four patients (51 women, 33 men), with a mean age of 34 years, underwent operation (right segmental colectomy: 55%; left segmental colectomy: 40%; associated right and left colectomy: 5%). A stoma was established in 27 patients (32%). Operative mortality was zero. Twelve patients (14%) had postoperative complications (including six cases of anastomotic leakage). The mean and median followup times were 111 and 104 months, respectively (range: 15 to 276 months) for the 82 patients with followup available. Thirty-six patients had to undergo reoperation, and the mean time to reoperation was 4.5 years. Twenty-six of these patients suffered colonic recurrence and were treated by total colectomy (n = 9) or new segmentary resection (n 17). The only factor that correlated with the risk of recurrence was youth. At the end of the study, 13 patients still had a stoma. Seventy-five percent of the patients without stoma had less than three bowel movements per day, and 80% were fully satisfied or satisfied,

CONCLUSIONS

There is no evidence of a higher risk of postoperative complications, surgical recurrence, or the requirement of a permanent stoma in patients suffering from colonic Crohn's disease who are treated according to a "bowel-sparing policy" compared with patients treated with more extensive resections published in the literature. Prospective randomized studies are needed to validate this observation.

Fate of the rectum in patients undergoing total colectomy for Crohn's disease

BACKGROUND

This study aimed to analyse disease recurrence and fate of the rectum in patients who had a total colectomy for Crohn's disease.

METHODS

One hundred and forty-four patients who had a total colectomy for Crohn's colitis were reviewed retrospectively. Ileorectal anastomosis (IRA) was performed in 118 patients, while 26 never had an IRA after colectomy because of severe anorectal lesions. Factors associated with recurrence and rectal preservation failure were studied.

RESULTS

The probability of clinical recurrence after IRA was 58 and 83 per cent at 5 and 10 years respectively. The probability of rectal preservation at 5 and 10 years was 70 and 63 per cent after colectomy, and 86 and 86 per cent after IRA, respectively. Patients with extraintestinal manifestation had a higher risk of recurrence and of rectal preservation failure. Previous ileal involvement was associated with a higher rate of ileal recurrence after IRA. After IRA, prophylactic treatment with 5-aminosalicylic acid was associated with a lower rate of recurrence and of failure to preserve the rectum.

CONCLUSION

Overall, 63 per cent of patients had a functioning IRA 10 years after total colectomy. Absence of extraintestinal manifestation and prophylactic treatment with 5-aminosalicylates after IRA were the main factors associated with long-term rectal preservation.

[Surgical treatment of Crohn's disease of the large intestine: do rectal complications influence the results of ileorectal anastomosis?]

STUDY AIM

The purpose of this retrospective study was to compare the morbidity and long-term outcome of patients undergoing total colectomy and ileorectal anastomosis (IRA) performed for Crohn's colitis with or without associated proctitis.

PATIENTS AND METHODS

Thirty-nine patients with a mean age of 35 years (17-72 years) underwent total colectomy with IRA. Patients were retrospectively classified into two groups; group 1 (28) without rectal involvement; group 2 (11) with proctitis. Follow-up data were obtained during 1998, by reviewing all patients. Mean postoperative follow-up was 10.6 years (1.5-22).

RESULTS

There were no postoperative deaths. Six (15%) patients experienced postoperative complications, with no difference between the two groups. Sixteen patients (41%) developed recurrence requiring surgery: 9 in group 1 (32%) and 7 in group 2 (64%) (p > 0.05). The IRA had to be removed or was no longer functional in 12 patients: 6 in group 1 (21.5%) and 6 in group 2 (54.5%) (p < 0.05).

CONCLUSION

Moderate proctitis does not increase the morbidity of total colectomy with IRA for Crohn's disease. The risk of reoperation and secondary protectomy is higher when proctitis was present, but the IRA was still functional in one-half of patients after more than 10 years of follow-up.

Total colectomy for Crohn's disease

BACKGROUND

Total colectomy for Crohn's disease of the colon may be restorative with ileorectal anastomosis or with an ileostomy and rectal stump. The present paper retrospectively audits the results of total colectomy and in particular assesses the number of patients who had a permanent ileostomy and whether this was related to disease in the rectum at the time of the original operation.

METHODS

A retrospective case note review was undertaken of patients operated upon between 1968 and 1994.

RESULTS

Thirty-eight patients were identified (mean age 35 years; range 17-65 years). One patient died perioperatively from an anastomotic leak. Median follow-up for the remaining patients was 7 years (range 1-29 years). Ileorectal anastomosis was performed in 17 patients and total colectomy and ileostomy in 20 patients. Indications for surgery were failure of medical treatment (61%); toxic colitis (18%); abscess (8%); perforation (5%); large bowel obstruction (5%); and colovesical fistula (3%). Subsequent proctectomy (14 patients, 38%) was more likely with subtotal colectomy and ileostomy (nine patients, 45%) than ileorectal anastomosis (five patients, 29%). This was not statistically significant (P = 0.33). Additionally, seven patients had diversion of the rectum making 21 with an ileostomy (57%). Rectal involvement at the time of the original procedure significantly increased the likelihood of permanent ileostomy (P = 0.001). The presence of anal disease did not increase the prospect of ileostomy. One patient died with advanced adeno carcinoma in a defunctioned rectum.

CONCLUSIONS

A permanent ileostomy after total colectomy for Crohn's disease is common and significantly more likely with rectal involvement.

Controversies in Crohn's disease

Despite recent advances in the medical therapy of Crohn's disease, surgery continues to play a central role in the treatment of the disease. The strategy for surgical management of Crohn's disease continues to evolve. This chapter reviews many of the controversies surrounding surgical palliation of complications of Crohn's disease. Included is a discussion of indications for strictureplasty in treatment of intractable intestinal obstruction. Factors influencing long-term outcome with sphincter-saving resection in the treatment of Crohn's colitis are reviewed. Experience with definitive treatment of anal Crohn's disease and repair of rectovaginal fistulas is examined. Finally, recent experience supporting ileocolic resection when acute Crohn's ileitis is identified during laparotomy for right lower quadrant pain is critically evaluated. These controversial aspects of the surgical treatment of Crohn's disease reflect an improved understanding of the natural history of the disease as well as refinement in surgical techniques and better definition of criteria for surgical intervention.

Surgical therapy for Crohn's disease of the colon and rectum

Crohn's disease remains incurable by either medical or surgical treatment. Both physician and surgeon must work together with the common objective of restoring health by eliminating or alleviating the complications of Crohn's disease. From the surgeon's viewpoint, operation is performed for complications of the disease or for failure of medical management. Although aggressive surgical excision of affected bowel rids the patient of disease for a period of time, the beneficial effects of operation have to be considered in the context that disease recurrence is always a possibility and that reoperation for such complications may be necessary. The aim of the surgeon is to deal with the current problem as simply as possible and to maintain a long-term, strategic view of the disease process with the understanding that what is done today may affect the patient for life.

Avoiding a stoma: role for segmental or abdominal colectomy in Crohn's colitis

Total proctocolectomy and ileostomy for Crohn's colitis offers a low recurrence rate but commits patients to a permanent ileostomy. In contrast, segmental resection may predispose patients to recurrence and further surgery but may delay or avoid a stoma in select individuals.

AIM

This study was undertaken to determine the risk of recurrence and the need for permanent stoma in patients treated with segmental or abdominal colectomy for Crohn's colitis.

METHODS

Between 1976 and 1985, 699 patients underwent surgery for Crohn's colitis at the Mayo Clinic. Patients who had a total proctocolectomy and end ileostomy or primary ileal or anorectal disease were excluded from further study. Fifty-three patients had a colon resection without a permanent stoma, and 49 were alive and available for follow-up. During a mean follow-up of 14 years, completed questionnaires provided current details on subsequent medical and surgical therapies and/or stomas that were required. In these 49 patients, Crohn's of the colon involved the right, left, and both sides of the colon in 12, 31, and 6 patients, respectively, and involved less than one-third, one to two-thirds, and greater than two-thirds of the colon in 23, 25, and 1 patients, respectively.

RESULTS

Twenty-two of forty-nine patients (45 percent) required no further therapy. In 27 patients (55 percent), further treatment was required, including 11 (22 percent) patients who were managed medically (only 4 >1 year) and 16 (33 percent) patients who were managed surgically. Three recurrences developed in the small bowel; the remaining 24 developed in the colon. For the 16 patients with recurrence requiring surgery, mean time to recurrence was 51 +/- 14 months; in all cases, recurrent disease involved the colon, with four anastomotic recurrences. At first recurrence, ten patients underwent another limited colon resection, and six patients underwent completion proctectomy with permanent ileostomy. Five patients required a third procedure, only one of which resulted in a permanent ileostomy. Therefore, 42 patients (86 percent) remained stoma-free, and 7 (14 percent) ultimately required permanent ileostomy, with a mean stoma-free interval of 23 +/- 4 months.

CONCLUSION

Colon resection without proctectomy in select patients with limited colonic Crohn's disease can delay or avoid the necessity of a permanent stoma.

Crohn's disease in the Hunter Valley region of Australia

Between 1967 and 1991, 130 patients underwent surgery for Crohn's disease at The Royal Newcastle Hospital, New South Wales. There were more patients in recent years, which suggested an increased incidence of the condition (2.1/100 000/per year). The clinical profile and recurrence rate were similar to other studies. However, a greater proportion of patients required surgery for chronic small bowel obstruction and fulminant colitis compared with patients in other countries.

Colectomy and ileorectal anastomosis in patients with Crohn's disease

Eighty-three patients underwent colectomy and ileorectal anastomosis for Crohn's disease of the large bowel. There were two postoperative deaths and seven anastomotic leaks. Fifty-two patients retained a functioning anastomosis with a mean follow-up of 8 years. Forty had an excellent or good functional result. The cumulative proportion of patients with a functioning ileorectal anastomosis was 77 and 63 per cent at 5 and 10 years respectively. Patients presenting with perforating Crohn's disease had a significantly increased risk of failure of the anastomosis. Perianal Crohn's disease following ileorectal anastomosis was significantly related to the need to defunction or excise the rectum.

Prediction of early symptomatic recurrence after intestinal resection in Crohn's disease

OBJECTIVE

This study was performed to identify clinical criteria that may help recognize patients with Crohn's disease who are at high risk for early symptomatic postoperative recurrence.

SUMMARY BACKGROUND DATA

Currently, no reliable criteria are available to help recognize patients who are prone to experience early symptomatic recurrence.

METHODS

One hundred sixty-four patients undergoing intestinal resection for Crohn's disease at the Mount Sinai Hospital between 1976 and 1989 were studied prospectively. Patients with symptomatic recurrent disease within 36 months were defined as having an early recurrence.

RESULTS

Multivariate analysis revealed that the number of anastomoses was the most important prognostic indicator (p = 0.001), followed by inflammation at the resection margins (p < 0.05). Patients requiring an ileostomy had a significantly lower early recurrence rate than those having single or multiple anastomoses. There was no significant correlation between inflammation at the margins and early recurrence in patients requiring an ileostomy (n = 38), or a single anastomosis (n = 98). When the margins were examined in the 28 patients with 2 or more anastomoses, 10 of 11 patients (91%) with inflammation at either margin experienced early recurrence. Patients having multiple anastomoses with normal margins had the same recurrence rate as patients with single anastomosis (42%).

CONCLUSIONS

Patients with extensive Crohn's disease requiring multiple resections with anastomosis, especially when microscopic inflammation is present at the margins, are at very high risk for symptomatic early recurrence. Ileostomy seems to be associated with a significantly lower early recurrence potential than anastomosis. Further study is needed to determine whether avoidance of multiple anastomosis and adjuvant medical treatment can alter the course of the disease after intestinal resection in patients at high risk for early symptomatic recurrence.

Outcome of ileorectal anastomosis for Crohn's colitis

One hundred thirty-one patients underwent ileorectal anastomosis (IRA) for Crohn's colitis. Preoperatively, 84 patients (63 percent) were found to have mild or moderate proctitis and 47 (37 percent) had rectal sparing. Sixty-eight (52 percent) had associated small bowel disease, and 20 (15 percent) had perianal disease. Sixty-five IRAs were performed at the time of subtotal colectomy, while 56 were done after previous surgery. Anastomotic leaks occurred in four patients. There were no operative deaths. Thirteen patients (10 percent) with protecting stomas never underwent closure. Among the remaining 118 patients with functioning IRAs, 30 (23 percent) required later proctectomy and 16 (13 percent) required proximal diversion, with the mean period with a functioning IRA in these 46 patients being 4.1 years (range, 6.2 months-12.7 years). An additional 13 patients required preanastomotic resection and neo-IRA, and 11 required proximal small bowel resection. The mean duration of function of all 118 IRAs was 9.2 years. At the time of review, after a mean follow-up of 9.5 years, 72 patients (61 percent) retained a functioning IRA, with 44 being free of disease, while 28 were being treated with steroids or antidiarrheal medication. The mean stool frequency was 4.7 per day. In patients with Crohn's colitis, IRA should be considered as an alternative to proctocolectomy if the rectum is not severely diseased and sphincter function is not compromised.

Consequences of ileal pouch-anal anastomosis for Crohn's colitis

Patients with Crohn's colitis are generally not considered candidates for the ileal pouch-anal anastomosis (IPAA) procedure. We reviewed 362 consecutive patients undergoing IPAA and analyzed the outcome of this procedure on 25 patients with a preoperative diagnosis of mucosal ulcerative colitis who were subsequently proven to have Crohn's disease. The mean follow-up was 38.1 months. Sixteen patients have a functioning pouch, seven have required pouch excision, one is diverted, and one has died. Only one of nine patients in whom there was a preoperative clinical feature suggestive of Crohn's disease has a functioning pouch, with complications uniformly occurring within months of ileostomy closure. In contrast, 15 of 16 patients without preoperative features of Crohn's disease have maintained their pouch, generally with good results. These data suggest that patients in whom there is clinical and pathologic evidence of Crohn's disease do very poorly without meaningful symptom-free intervals. However, patients without any clinical features of Crohn's disease, despite a histopathologic diagnosis of Crohn's colitis, have had a good outcome with IPAA thus far.

Recurrence of Crohn's disease after resection

Recurrent Crohn's disease develops in most patients after surgical resection if the patient is followed for sufficient time. This review examines various aspects of recurrent Crohn's disease. It is concluded that Crohn's disease is a diffuse condition of the gastrointestinal tract and that radical resection of Crohn's disease does not prevent recurrence. Assorted factors thought to be associated with recurrence are examined and the relevance of these factors to the surgeon treating Crohn's disease is discussed.

Segmental colonic resection is an appropriate operation for short skip lesions due to Crohn's disease in the colon

Thirty-six patients have had a segmental colonic resection for Crohn's colitis between 1948 and 1984. There were 2 deaths caused by intraabdominal abscesses present before operation. There were no cases of anastomotic dehiscence in the 29 patients having segmental resection and immediate anastomosis. The reoperation rate at 10 years was 66% (95% confidence interval, 48-84%), the majority of reresections being for recurrent large bowel Crohn's disease. The 10-year reoperation rates were higher than after subtotal colectomy and ileorectal anastomosis (53%; 95% confidence interval, 37-69%) performed in a comparable group of patients with colonic Crohn's disease. The difference did not achieve statistical significance. These findings suggest that when a patient with Crohn's disease has a short segment of diseased large bowel, a segmental resection is feasible and safe.

Measurement of rectal capacity in the assessment of patients for colectomy and ileorectal anastomosis in Crohn's colitis

A group of 38 patients with Crohn's colitis underwent measurement of rectal capacity prior to colectomy and ileorectal anastomosis. Median values for constant and maximum tolerated volumes were significantly higher in patients who still possessed a satisfactorily functioning ileorectal anastomosis at a mean follow-up of 6.8 years, and measurement of these sensory parameters of rectal capacity was of prognostic value in predicting the likely outcome of ileorectal anastomosis.

Recurrent small bowel Crohn's disease is more frequent after subtotal colectomy and ileorectal anastomosis than proctocolectomy

The cumulative probability of reoperation for recurrent ileal Crohn's disease at five years was: 17 percent following ileocecal resection, 19 percent following proctocolectomy, and 28 percent after ileorectal anastomosis. At ten years, the rate of ileal recurrence was significantly less after proctocolectomy; 24 percent as compared with 43 percent for ileorectal anastomosis (P less than 0.01), whereas ileocecal resection assumed an intermediary position with 35 percent.

The long-term results of excisional surgery for primary and recurrent Crohn's disease of the large intestine

Two-hundred and seven survivors of excisional surgery for primary Crohn's disease of the large intestine have been followed for a mean period of 15 years (range, 7 to 25 years). Of the 45 patients who were treated by colectomy and ileorectal anastomosis, 32 (71 percent) developed recurrence in the terminal ileum, rectum, or ileum and rectum, (and in the duodenum in one). Most recurrences appeared during the first few years, but there appeared to be some continuing predisposition to recurrence indefinitely. Nineteen of the patients with recurrences proceeded to rectal excision and ileostomy. A total of 17 patients (3 percent) with or without recurrence had good functional results with a retained ileorectal anastomosis. Of the 162 patients who were treated by ileostomy and colectomy or proctocolectomy (rarely rectal excision and iliac colostomy), 24 (14.8 percent) had recurrences, usually in the bowel immediately above the stoma and, occasionally, more extensively elsewhere. Most recurrences manifested themselves in the first eight to ten years after operation, and the continuing predisposition thereafter was relatively slight. The inconvenience occasioned by the stoma in these 162 patients was rated as nil in 36.4 percent, negligible in 33.3 percent, moderate or severe in 25.3 percent, and ileostomy refashioning was performed in 5.0 percent with improvement in most instances. The overall condition of the 162 patients was considered to be excellent in 71 percent, fair in 22.8 percent, and poor in 6.2 percent.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical impact of colectomy and ileorectal anastomosis in the management of Crohn's disease

We report the outcome of 63 consecutive patients with Crohn's colitis treated by colectomy and ileorectal anastomosis between 1951-1981. There were no operative deaths. Serious postoperative complications occurred in 10 patients. The mean follow up since colectomy was 9.5 years. At 10 years the cumulative reoperation rate was 48% and the cumulative recurrence rate (based upon operative, radiological, and sigmoidoscopic evidence) was 64%. Ten patients have died during follow up. Two-thirds of the patients still under review have an intact ileorectal anastomosis. These results show that colectomy and ileorectal anastomosis is a useful operation in young patients with chronic ill health, diarrhoea, and anaemia in whom there is minimal anorectal disease. For suitable patients, the operation avoids the morbidity of a permanent stoma, pelvic dissection, and rectal excision. Recurrence developing in the ileum proximal to the anastomosis can often be resected and intestinal continuity preserved, whereas anorectal recurrence usually requires proctectomy.

The Kock reservoir ileostomy: a review of its development, problems and role in modern surgical practice

The Kock continent ileostomy reservoir was designed in an attempt to overcome many of the problems associated with the conventional ileostomy. An account is given of the technical developments of this procedure since its inception. An intussusception valve within the reservoir is necessary for continence. However, valve failure is a common problem and the developments in construction which have helped to overcome this are described. The major complications associated with the continent ileostomy are discussed in detail, and an attempt is made to define its present role in the treatment of inflammatory disease of the colon.

Assessment of anorectal function in selection of patients for ileorectal anastomosis in Crohn's colitis

Anorectal function has been assessed in 53 patients with Crohn's disease by measurement of resting and squeeze anal canal pressures and the maximum volume tolerated during distension of a balloon in the rectum. Radiographs of the rectum from barium enema examination were also reviewed to assess rectal capacity. Thirty-three patients have had a colectomy and ileorectal anastomosis for Crohn's colitis of whom 13 now have a stoma because they either required a protectomy (n=9) or where closure of a loop ileostomy had not been possible (n=4) because of severe anorectal disease. The maximum tolerated volume was less than 150 ml in 12 of 13 patients who now have a stoma compared with none of the 20 patients who have a functioning anastomosis. Although the correlation between a radiological assessment of rectal capacity and the maximum tolerated volume was poor, a severely contracted rectum was associated with the need for a stoma in six of seven patients compared with only two of 13 patients who did not have radiological signs of a narrow rectum.