Colectomy and ileorectal anastomosis in patients with 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.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Long-term Outcomes of Sphincter-Saving Procedures for Diffuse Crohn's Disease of the Large Bowel

BACKGROUND

Total abdominal colectomy with ileorectal anastomosis for Crohn's colitis is acceptable in the presence of a suitable rectum. Intentional IPAA has been proposed for diffuse Crohn's proctocolitis without enteric or anoperineal disease.

OBJECTIVE

The aim of this study was to evaluate the long-term outcomes of sphincter-saving procedures for large-bowel Crohn's disease.

DESIGN

Patients with preoperative Crohn's disease diagnosis undergoing intentional IPAA and ileorectal anastomosis were included.

SETTINGS

The study was conducted at a tertiary care research center.

PATIENTS

Ileorectal anastomosis was performed in 75 patients with Crohn's disease, whereas 32 patients underwent intentional IPAA.

MAIN OUTCOME MEASURES

Long-term functional results and permanent stoma requirement of sphincter-saving operations were assessed. Quality of life and postoperative medication use were also compared with a control group of patients undergoing total proctocolectomy and end ileostomy.

RESULTS

Patients undergoing ileorectal anastomosis were older and had longer disease duration, higher prevalence of perianal and penetrating disease, and history of small-bowel resection than those receiving IPAA. Indications for surgery, preoperative use of immunomodulators, and postoperative use of biologics were also significantly different. Although functional defecatory outcomes were comparable, reported quality of life 3 years after surgery was significantly better in patients who underwent IPAA than in patients with ileorectal anastomosis. Patients with IPAA were associated with significantly lower cumulative rates of surgical recurrence (HR = 0.28 (95% CI, 0.09-0.84); p = 0.017), indefinite stoma diversion (HR = 0.35 (95% CI, 0.13-0.99); p = 0.039), and proctectomy with end ileostomy (HR = 0.27 (95% CI, 0.07-0.96); p = 0.030) than those with ileorectal anastomosis.

LIMITATIONS

The study was limited by its retrospective nature and small sample size.

CONCLUSIONS

Contemporary patients selected to have intentional IPAA for Crohn's colitis have disease characteristics very different from those selected to have ileorectal anastomosis. Long-term follow-up confirms intentional IPAA as an acceptable option in selected patients with Crohn's colitis.

Risk of Neoplasia After Colectomy in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Colorectal neoplasia can still develop after colectomy for inflammatory bowel disease. However, data on this risk are scare, and there have been few conclusive findings, so no evidence-based recommendations have been made for postoperative surveillance. We conducted a systematic review and meta-analysis to determine the prevalence and incidence of and risk factors for neoplasia in patients with inflammatory bowel disease who have undergone colectomy, including the permanent-end ileostomy and rectal stump, ileorectal anastomosis (IRA), and ileal pouch-anal anastomosis (IPAA) procedures.

METHODS

We searched PubMed, Embase, Web of Science, and Cochrane Library through May 2014 to identify studies that reported prevalence or incidence of colorectal neoplasia after colectomy or specifically assessed risk factors for neoplasia development. Studies were selected, quality was assessed, and data were extracted by 2 independent researchers.

RESULTS

We calculated colorectal cancer (CRC) prevalence values from 13 studies of patients who underwent rectal stump surgery, 35 studies of IRA, and 33 studies of IPAA. Significantly higher proportions of patients in the rectal stump group (2.1%; 95% confidence interval [CI], 1.3%-3.0%) and in the IRA group (2.4%; 95% CI, 1.7%-3.0%) developed CRC than in the IPAA group (0.5%; 95% CI, 0.3%-0.6%); the odds ratio (OR) for CRC in the rectal stump or IRA groups compared with the IPAA group was 6.4 (95% CI, 4.3-9.5). A history of CRC was the most important risk factor for development of CRC after colectomy (OR for patients receiving IRA, 12.8; 95% CI, 3.31-49.2 and OR for patients receiving IPAA, 15.0; 95% CI, 6.6-34.5).

CONCLUSIONS

In a meta-analysis of published studies, we found the prevalence and incidence of CRC after colectomy to be less than 3%; in patients receiving IPAA it was less than 1%. Factors that increased risk of cancer development after colectomy included the presence of a residual rectum and a history of CRC. These findings could aid in development of individualized strategies for post-surgery surveillance.

Immediate outcome, long-term function and quality of life after extended colectomy with ileorectal or ileosigmoid anastomosis

AIM

Total/subtotal colectomy with ileorectal (IRA) or ileosigmoid (ISA) anastomosis is associated with various reported rates of morbidity, function and quality of life. Our object was to determine these end-points in a series of patients undergoing these operations in our institution.

METHOD

All patients who underwent IRA or ISA between 1994 and 2009 were retrospectively reviewed.

RESULTS

A total of 320 patients (female 49%) with a median age of 54.2 (16.8-90.6) years underwent 338 IRA or ISA (in 18 patients the anastomosis was done twice) for inflammatory bowel disease (n = 96), polyposis (n = 95) and colorectal cancer (n = 97). Mortality and morbidity rates were 1.2% (n = 4) and 19.5% (n = 66) and 47 surgical complications (13.9%) occurred, including 26 (7.7%) cases of anastomotic leakage, leading to 23 re-operations. After a median follow-up of 49 (0-196) months, 262 patients still had a functioning anastomosis; 45 patients had died and 13 had a proctectomy. Information on function was obtained in 51.4% (133/259) of the cohort after a median follow-up of 77 (10-196) months. The mean (± standard deviation) rates of 24 h and nocturnal defaecation were 3.6 ± 2.4 and 0.5 ± 0.9. A disturbance of faecal or flatus continence occurred in 20% and 21% of patients. There was no case of faecal incontinence to solid stool. The mean SF-36 Physical and Mental Health Summary Scales were 46.3 ± 9.3 and 51.9 ± 9.3. Multivariate analysis showed that IRA and inflammatory bowel disease were both independently associated with poorer long-term function.

CONCLUSION

Colectomy with IRA or ISA is safe with low postoperative morbidity and mortality. The employment of IRA and inflammatory bowel disease appear to be independent negative factors on function in multivariate analysis.

Restorative procedures in colonic crohn disease

Surgical management for refractory Crohn colitis often involves creation of a temporary or permanent stoma. Traditionally, the procedure of choice has been a total proctocolectomy with permanent ileostomy. However, restorative procedures that help to avoid a permanent stoma are being used with more frequency. In this article, the authors will address these procedures, including colocolonic anastomosis, ileorectal anastomosis, ileal pouch rectal anastomosis, and ileal pouch anal anastomosis. Factors that may influence one's decision to perform these procedures, such as patient age and nutritional status, medical comorbidities, sphincter function, desire to avoid a permanent ostomy, and prior medical therapy, will be discussed. Functional outcomes regarding these procedures will also be described. One should keep in mind that surgery does not cure Crohn disease and that postoperative long-term management is essential in preventing progression or recurrence of disease.

Long-term outcome of colectomy and ileorectal anastomosis for Crohn's colitis

BACKGROUND

Ileorectal anastomosis is an important surgical option for patients with Crohn's colitis with relative rectal sparing.

OBJECTIVE

This study aimed to audit outcomes of ileorectal anastomosis for Crohn's and factors associated with proctectomy and reoperation.

DESIGN

This retrospective study involved a chart review and contacting patients.

SETTINGS

Patients with Crohn's colitis who had an ileorectal anastomosis were identified from the Mount Sinai Hospital Inflammatory Bowel Disease Database.

PATIENTS

Demographics, operative and perioperative outcomes, and reoperative data were collected.

MAIN OUTCOME MEASURES

Five- and 10-year Kaplan-Meier survival estimates and 95% confidence intervals were calculated for survival from proctectomy and Crohn's-related revisional surgery. Cox proportional hazards models were used to model the hazards of proctectomy and Crohn's-related revision on the clinical characteristics of patients.

RESULTS

Eighty-one patients had an ileorectal anastomosis for Crohn's disease from 1982 to 2010. The most common indications for surgery were failed medical management (60/81, 74.1%) and a stricture causing obstruction (14/81, 17.3%). Seventy-seven percent (n = 62) had a 1-stage procedure, whereas 23% (n = 19) had a 2-stage procedure (colectomy followed by ileorectal anastomosis). The overall anastomotic leak rate was 7.4% (n = 6). Fifty-six patients had a functioning ileorectal anastomosis at the time of follow-up. At 5 and 10 years, 87% (95% CI: 75.5-93.3) and 72.2% (95% CI: 55.8-83.4) of individuals had a functioning ileorectal anastomosis. Eighteen patients required proctectomy for poor symptom control, whereas 11 patients required a small-bowel resection plus redo-ileorectal anastomosis. The mean time to proctectomy from the original ileorectal anastomosis was 88.3 months (SD = 62.1). Smoking was associated with both proctectomy (HR 3.93 (95% CI: 1.46-10.55)) and reoperative surgery (HR 2.12 (95% CI: 0.96-4.72)).

LIMITATIONS

: This study was retrospective.

CONCLUSIONS

Ileorectal anastomosis is an appropriate operation for selected patients with Crohn's colitis with sparing of the rectum. However, patients must be counseled that the reoperation rate and/or proctectomy rate is approximately 30%.

Colectomy in patients with acute colitis: a systematic review

BACKGROUND

For patients with acute colitis, the decision when and how to operate is difficult in most cases. It was the aim of this systematic review to analyze early mortality and morbidity of colectomy for severe acute colitis in order to identify opportunities to improve perioperative treatment and outcome.

METHODS

A systematic review of the available literature in the Medline and PubMed databases from 1975 to 2007 was performed. All articles were assessed methodologically; the articles of poor methodological quality were excluded. Articles on laparoscopic colectomy for acute colitis were analyzed separately.

RESULTS

In total, 29 studies met the criteria for the systematic review, describing a total of 2,714 patients, 1,257 of whom were operated on in an acute setting, i.e., urgent or emergency colectomy. Reported in-hospital mortality was 8.0%; the 30-day mortality was 5.2%. Morbidity was 50.8%. The majority of complications were of infectious and thromboembolic nature. Over the last three decades, there was a shift in indications from toxic megacolon, from 71.1% in 1975-1984 to 21.6% in 1995-2005, to severe acute colitis not responding to conservative treatment, from 16.5% in 1975-1984 to 58.1% in 1995-2007. Mortality decreased from 10.0% to 1.8%. Morbidity remained high, exceeding 40% in the last decade. Mortality after laparoscopic surgery was 0.6%. Complication rate varies from 16-37%.

CONCLUSION

Colectomy for acute colitis is complicated by considerable morbidity. The incidence of adverse outcome has substantially decreased over the last three decades, but further improvements are still required. The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions about both conventional and laparoscopic surgery.

Safety and efficacy of strictureplasty for Crohn's disease: a systematic review and meta-analysis

PURPOSE

This study was designed to review safety and efficacy of strictureplasty for Crohn's disease.

METHODS

A literature search was performed to identify studies published between 1975 and 2005 that reported the outcome of strictureplasty. Systematic review was performed on the following subjects separately: 1) overall experience of strictureplasty; 2) postoperative complications; 3) postoperative recurrence and site of recurrence; 4) factors affecting postoperative complications and recurrence; 5) short-bowel syndrome; and 6) cancer risk. Meta-analysis of recurrence rate after strictureplasty was performed by using random-effect model and meta-regressive techniques.

RESULTS

A total of 1,112 patients who underwent 3,259 strictureplasties (Heineke-Mikulicz, 81 percent; Finney, 10 percent; side-to-side isoperistaltic, 5 percent) were identified. The sites of strictureplasty were jejunum and/or ileum (94 percent), previous anastomosis (4 percent), duodenum (1 percent), and colon (1 percent). After jejunoileal strictureplasty, including ileocolonic strictureplasty, septic complications (leak/fistula/abscess) occurred in 4 percent of patients. Overall surgical recurrence was 23 percent (95 percent confidence interval, 17-30 percent). Using meta-regressive analysis, the five-year recurrence rate after strictureplasty was 28 percent. In 90 percent of patients, recurrence occurred at nonstrictureplasty sites, and the site-specific recurrence rate was 3 percent. Two patients developed adenocarcinoma at the site of previous jejunoileal strictureplasty. The experience of duodenal or colonic strictureplasty was limited.

CONCLUSIONS

Strictureplasty is a safe and effective procedure for jejunoileal Crohn's disease, including ileocolonic recurrence, and it has the advantage of protecting against further small bowel loss. However, the place for strictureplasty is less well defined in duodenal and colonic diseases.

Effect of ulcerative colitis in the bursting strength of colonic anastomoses in rats

Inflammatory bowel disease may have a deleterious effect on bowel healing, but its role is difficult to demonstrate in clinical practice because of the association of multiple factors. An experiment was conducted in rats. They were divided into two groups: group I, a model of acetic acid induced colitis, and group II, the control group. Both groups underwent a rectal resection and primary anastomosis. On postoperative day 7, the bursting strength of the anastomosis was evaluated. There were 44 rats in group I and 38 in group II. In 91% of group I rats there were histopathological changes compatible with inflammatory bowel disease (IBD). Mean bursting pressure was significantly reduced in rats with acetic-acid induced IBD (142.18 +/- 18.22 mm Hg in group I, and 208.85 +/- 14.8 mm Hg in group II; p < .05). These results suggest the deleterious effect of IBD on bowel healing.

Urologic manifestations of nonurologic diseases gastrointestinal disorders

A variety of common, gastrointestinal diseases result in significant genitourinary tract pathology. In general, knowledge of these associated disease processes permit rapid and accurate diagnosis and treatment. The underlying thread is the recognition of one pathophysiological process to explain patterns of a single disease.

Mortality, morbidity and functional outcome after ileorectal anastomosis

BACKGROUND

Total colectomy with an ileorectal anastomosis (IRA) is a commonly performed operation. Postoperative mortality and morbidity are reported to be low and functional outcome is generally rated as good to excellent. The aim of this study was to review postoperative mortality, morbidity and functional results in an effort to identify risk factors predictive of a poor outcome.

METHODS

Some 215 patients (118 women and 97 men) with a median age of 33 (interquartile range (i.q.r.) 25-47) years underwent an IRA between November 1990 and December 1999. Median follow-up was 2 years 9 months (i.q.r. 1-5 years). The clinical notes of these patients were reviewed retrospectively to analyse the postoperative course, bowel function and long-term clinical outcome.

RESULTS

The indications for surgery included familial adenomatous polyposis (52.1 per cent), Crohn's disease (14.4 per cent), functional bowel disorder (14.4 per cent), ulcerative colitis (8.4 per cent) and colonic carcinoma (4.7 per cent). The overall 30-day mortality and morbidity rates were 0.9 and 26.0 per cent respectively. This included anastomotic leak (6.5 per cent), small bowel obstruction (14.4 per cent), fistula (2.8 per cent) and anastomotic stricture (1.4 per cent). The incidence of fistula and anastomotic stricture was significantly higher in Crohn's disease (P < 0.001 and P = 0.005 respectively). Only 16 of 31 patients with Crohn's disease had a functioning IRA at long-term follow-up. Median stool frequency was 3 (i.q.r. 3-5) per day one year following surgery and did not change with longer follow-up.

CONCLUSION

Mortality and morbidity rates following IRA are low. Postoperative fistula and anastomotic stricture are more common in patients with Crohn's disease, approximately half of whom will eventually need a permanent ileostomy. Long-term bowel function for all groups is satisfactory.

Recurrence after colectomy in Crohn's colitis

PURPOSE

Previous studies on recurrence and reoperation after colectomy in Crohn's colitis have been based on heterogeneous groups of patients, and divergent findings may be explained by referral biases and small numbers of patients. The aim of this study was to account for recurrence rates, present risk factors for recurrence after primary colectomy, and account for the ultimate risk of having a stoma after colectomy with ileorectal anastomosis in patients with Crohn's colitis.

METHODS

Data on the primary resection, postoperative recurrence, influence of concomitant risk factors, frequency of stoma operations and proctectomy were evaluated retrospectively using multivariate analysis in a population-based cohort of 833 patients with Crohn's colitis.

RESULTS

The cumulative 10-year risk of a symptomatic recurrence was 58 percent (95 percent confidence interval, 53-63 percent) and 47 percent (95 percent confidence interval, 42-52 percent), respectively, after colectomy with ileorectal anastomosis and segmental colonic resection. In colectomy with ileostomy, lower rates were found with respectively 24 percent (95 percent confidence interval, 18-30 percent) and 37 percent (95 percent confidence interval, 32-43 percent) after subtotal colectomy and proctocolectomy with ileostomy. The multivariate analysis showed that perianal disease, ileorectal anastomosis, and segmental resection were independent risk factors for postoperative recurrence. In 76 percent of patients with ileorectal anastomosis, a stoma-free function could be retained during a median follow-up of 12.5 years.

CONCLUSION

Colectomy with ileorectal anastomosis or segmental resection is a feasible option in the surgical treatment of Crohn's colitis, although anastomoses, in addition to perianal disease, carry an increased risk of recurrent disease.

Evolutive pattern in Crohn's disease: a simplified index using clinical parameters predicts obstructive behaviour

BACKGROUND

Two clearly differentiated evolutive patterns of Crohn's disease, obstructive and fistulizing, exist, but the early clinical parameters which can predict the evolution are unknown.

AIM

To evaluate whether clinical variables, present at the time of diagnosis, may help in predicting a subsequent evolutive behaviour.

PATIENTS AND METHODS

Ninety out of 140 evaluable patients were included. After a median of 50.2 months since diagnosis, 64 patients (71%) followed an obstructive pattern while 26 patients (28.9%) had a fistulizing form. Clinical variables were analysed as predictors of outcome. Logistic regression was carried out in order to obtain a mathematical model that would predict the evolution. The individual ability of the mathematical model to predict evolution was assessed using relative receiver operating characteristic (ROC) curves.

RESULTS

The variables which were retained in the model were duration of disease before diagnosis (DD), onset of symptoms (OS), presence of anal disease (AD) and the presence of abdominal mass (AM). The equation z = -9.49 + 2.2643 (AD) - 0.0066 (DD) + 2.5282 (AM) + 1.3433 (OS) was obtained. The probability of evolution towards an obstructive form was P = 1/(1 + e(-Z)). This model can predict 96.88% of obstructive forms but only 53.85% of fistulizing forms. The mathematical point section (ROC curve) corresponds to a probability of 45.2%. Considering an obstructive pattern when the probabilities are above this point, the sensitivity is 98% and the specificity is 50%.

CONCLUSIONS

The prediction of an obstructive pattern is feasible using simple clinical variables. The mathematical model obtained is useful for predicting this but not the fistulizing pattern.

Crohn's disease of the colon

The surgical treatment of Crohn's disease of the colon is distinct from that used in treating ulcerative colitis. Crohn's disease often involves the small bowel and is not "cured" by colorectal resection. The popular ileo-anal pouch procedures used in the management of ulcerative colitis generally are not used for the treatment of Crohn's colitis, because of higher complication rates. Commonly performed operations include ileostomy, segmental colon resection, subtotal colectomy, and proctocolectomy. The general surgeon, therefore, is provided with many options when faced with complications of Crohn's colitis. This article examines the attributes of and results reported for each of these options.

Risk factors for intra-abdominal sepsis after surgery in Crohn's disease

PURPOSE

This study examined risk factors for intra-abdominal sepsis after surgery in Crohn's disease.

METHODS

We reviewed 343 patients who underwent 1,008 intestinal anastomoses during 566 operations for primary or recurrent Crohn's disease between 1980 and 1997. Possible factors for intra-abdominal sepsis were analyzed by both univariate (chi-squared test) and multivariate (multiple regression) analyses.

RESULTS

Intra-abdominal septic complications, defined as anastomotic leak, intra-abdominal abscess, or enterocutaneous fistula, developed after 76 operations (13 percent). Intra-abdominal septic complications were significantly associated with preoperative low albumin level (< 30 g/l; P = 0.04), preoperative steroids use (P = 0.03), abscess at the time of laparotomy (P = 0.03), and fistula at the time of laparotomy (P = 0.04). The intra-abdominal septic complication rate was 50 percent (8/16 operations) in patients with all of these four risk factors, 29 percent (10/35 operations) in patients with three risk factors, 14 percent (14/98 operations) in patients with two risk factors, 16 percent (33/209 operations) in patients with only one risk factor, and 5 percent (11/208 operations) in patients with none of these risk factors (P<0.0001). The following factors did not affect the incidence of septic complications; age, duration of symptoms, number of previous bowel resections, site of disease, type of operation (resection, strictureplasty, or bypass), covering stoma, and number, site, or method (sutured or stapled) of anastomoses.

CONCLUSIONS

Preoperative low albumin level, steroid use, and the presence of abscess or fistula at the time of laparotomy significantly increased the risk of septic complications after surgery in Crohn's disease.

Proctocolectomy is associated with a higher complication rate but carries a lower recurrence rate than total colectomy and ileorectal anastomosis in Crohn colitis

BACKGROUND

Most patients with extensive colonic Crohn disease are treated with total colectomy and ileorectal anastomosis or, when there is severe anorectal disease, with proctocolectomy. This study was undertaken to compare postoperative complications and recurrence rates for these two operations.

METHODS

Eighty-six patients who underwent a single-stage proctocolectomy and 65 who underwent total colectomy and ileorectal anastomosis for colonic Crohn disease were retrospectively reviewed.

RESULTS

Anorectal disease (severe proctitis, perianal sepsis, complex fistula) was seen in 77 patients (90%) at proctocolectomy, compared with 7 patients (11%) at colectomy and ileorectal anastomosis (P < 0.0001). After proctocolectomy the commonest complication was perineal wound sepsis (36%). After colectomy and ileorectal anastomosis only three patients (5%) developed anastomotic leak. The overall complication rate was 53% after proctocolectomy compared with 32% after colectomy and ileorectal anastomosis (P = 0.02). Twenty-four patients (29%) after proctocolectomy and 43 patients (68%) after colectomy and ileorectal anastomosis developed symptomatic recurrence (P < 0.0001). After proctocolectomy the 5-, 10-, and 15-year cumulative reoperation rate for recurrence were 13%, 16%, and 26%, which were significantly lower than the 29%, 46%, and 48% after colectomy and ileorectal anastomosis (P = 0.002).

CONCLUSIONS

The overall complication rate was lower after colectomy and ileorectal anastomosis than after proctocolectomy. However, proctocolectomy was associated with a lower incidence of reoperation for recurrence than colectomy and ileorectal anastomosis.

Perforating ileocecal Crohn's disease does not carry a high risk of recurrence but usually re-presents as perforating disease

PURPOSE

The aim of this study was to study the natural history of perforating and nonperforating ileocecal Crohn's disease.

METHODS

One hundred sixty-five cases of primary ileocecal Crohn's disease operated on between 1975 and 1995 were reviewed. Perforating disease was defined as acute free perforation, subacute perforation with an abscess, or chronic perforation with an internal or external fistula.

RESULTS

Perforating disease was identified in 72 patients (44 percent); 11 with acute free perforation, 18 with abscess formation, and 43 with fistulas. Postoperative complications occurred in 29 percent of perforating and in 23 percent of nonperforating disease (not a significant difference). There was no significant difference in the cumulative reoperation-free rate for recurrence at the ileocolonic anastomosis (perforating, 78 percent vs. nonperforating, 73 percent at 5 years and perforating, 61 percent vs. nonperforating, 55 percent at 10 years), or in the median time interval from the primary to the secondary operation (perforating, 49 vs. nonperforating, 37 months). Seventy percent of perforating disease re-presented with perforating recurrence. Likewise, 83 percent of nonperforating disease re-presented with nonperforating (P < 0.0001) recurrence. Re-reoperation rate for re-recurrence at the ileocolonic anastomosis and median duration from the second operation to the third operation did not differ between perforating and nonperforating disease. Seventy-nine percent of perforating disease re-presented again with perforating disease, and 87 percent of nonperforating disease re-presented again with nonperforating disease as before (P = 0.001).

CONCLUSIONS

These data suggest that perforating ileocecal disease usually re-presents in the way it did originally but does not represent a high-risk group for recurrence.

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.

Long-term seton drainage for high anal fistulas in Crohn's disease--a sphincter-saving operation?

METHODS

Forty-one consecutive patients with Crohn's disease who underwent long-term seton drainage for high transsphincteric, suprasphincteric, or extrasphincteric anal fistula from 1985 to 1993 were reviewed. The subsequent associated procedure was simple seton removal (18), secondary fistulotomy (7), rectal flap advancement (3), and proctectomy (2). Eleven patients still had the seton in place.

RESULTS

Recurrence developed in seven patients (39 percent) undergoing simple seton removal and in one patient undergoing rectal flap advancement. None of the patients treated by secondary fistulotomy developed a recurrence. At the end of follow-up, five patients (12 percent) required proctectomy mainly for severe proctitis, and five patients (12 percent) developed anal incontinence, which was severe in two.

CONCLUSION

Long-term seton drainage for high and fistula in Crohn's disease is efficacious in both treating sepsis and preserving anal sphincter function.