Surgical treatment of Crohn's disease affecting mainly or entirely the large bowel

Anastomotic Considerations in Crohn's Disease

A number of factors should be considered when performing an intestinal anastomosis in the setting of surgery for Crohn's disease. Preoperative risk factors, such as malnutrition, abdominal sepsis, and immunosuppressive medications, may increase the risk of postoperative anastomotic complications and alter surgical decision-making. The anatomical configuration and technique of constructing the anastomosis may have an impact on postoperative function and risk of recurrence, particularly in the setting of ileocolic resection, where the Kono-S anastomosis has gained popularity in recent years. There may be circumstances in which it may be more appropriate to perform an ostomy either without an anastomosis or to temporarily divert an anastomosis when the risk of anastomotic complications is felt to be high. In the setting of total abdominal colectomy or proctocolectomy for Crohn's colitis, restorative procedures may appropriate in lieu of a permanent stoma in certain scenarios.

Surgical Treatment of Crohn Colitis Involving More Than 2 Colonic Segments: Long-Term Outcomes From a Single Institution

The incidence of primary Crohn colitis is uncommon and surgical treatment has remained controversial, although most patients with Crohn colitis eventually require surgical intervention. This study aims to compare the operative outcomes of patients who underwent segmental versus either total colectomy or total proctocolectomy for Crohn colitis and to assess potential risk factors associated with clinical and surgical recurrence-free survivals.This is a retrospective study of 116 patients who underwent primary surgery for Crohn colitis between August 1997 and July 2011. Patients were classified based on the type of surgery: segmental colectomy (SC group; n = 71) or either total colectomy or total proctocolectomy (TC group; n = 45).There were no significant differences in postoperative complications or the nutritional state between the SC and TC groups. Patients in TC group had a significantly higher clinical recurrence-free survival (CRFS). Among the 54 patients with multisegmental Crohn colitis, the TC group had a significantly increased CRFS and surgical recurrence-free survival (SRFS), compared with patients in the SC group (5-year CRFS: 82.0% ± 5.8% vs 22.2% ± 13.9%, P = 0.001; 5-year SRFS: 88.1% ± 5.0% vs 44.4% ± 16.6%, P = 0.001). By multivariate analysis of patients with multisegments involved, SC was a risk factor for SRFS and CRFS (hazard ratio [HR] = 4.637, 95% confidence interval [CI] = 1.387-15.509, P = 0.013 and HR = 32.407, 95% CI = 2.873-365.583, P = 0.005).TC patients have significantly increased CRFS and TC in patients with multisegment involvement may affect improved SRFS and CRFS. Among patients with multisegmental Crohn colitis, SC is an independent risk factor for CRFS and SRFS.

Clinical recurrence and re-resection rates after extensive vs. segmental colectomy in Crohn's colitis: a retrospective cohort study

BACKGROUND

The aim of the present study was to document long-term clinical recurrence and re-resection rates of segmental and extended colectomy in patients with Crohn's colitis and to identify risk factors causing recurrence.

METHODS

Records of patients with isolated colonic Crohn's disease who underwent colectomy between 1995 and 2013 and were followed at our medical center were identified. Data on age at diagnosis, gender, smoking, disease location at diagnosis, perianal and rectal disease, indication for surgery, preoperative disease duration, type of operation, primary anastomosis at first operation, length of resected specimen, recurrence of symptoms, postoperative medication, reoperation, and total follow-up time were retrieved.

RESULTS

Thirty-five suitable patients (18 segmental colectomy, 17 extensive colectomy; 17 males; mean age at operation 36.6 years) were identified. Mean age at primary operation was 36 years. The mean preoperative disease duration was 121 months. Postoperative medical treatment was needed in 10 (56 %) patients undergoing segmental colectomy and in 16 (94 %) of those undergoing extensive colectomy (p = 0.01). There was longer reoperation-free survival in the segmental colectomy patient group (p = 0.02) and also a trend toward longer symptom-free survival compared to the extensive colectomy patient group (p = 0.105). There was no correlation between the length of resected bowel and recurrence. Patients operated on at a younger age did not have a higher rate of recurrence of symptoms. Shorter disease duration, smoking, and male gender were risk factors for clinical recurrence.

CONCLUSIONS

Segmental resection with primary anastomosis can be safely performed in patients with limited Crohn's colitis with reasonable clinical recurrence rates.

A comparison of segmental vs subtotal/total colectomy for colonic Crohn's disease: a meta-analysis

OBJECTIVE

Using meta-analytical techniques the present study evaluated differences in short-term and long-term outcomes of adult patients with colonic Crohn's disease who underwent either colectomy with ileorectal anastomosis (IRA) or segmental colectomy (SC).

METHODS

Comparative studies published between 1988 and 2002, of subtotal/total colectomy and ileorectal anastomosis vs segmental colectomy, were used. The study end points included were surgical and overall recurrence, time to recurrence, postoperative morbidity and incidence of permanent stoma. Random and fixed-effect meta-analytical models were used to evaluate the study outcomes. Sensitivity analysis, funnel plot and meta-regressive techniques were carried out to explain the heterogeneity and selection bias between the studies.

RESULTS

Six studies, consisting of a total of 488 patients (223 IRA and 265 SC) were included. Analysis of the data suggested that there was no significant difference between IRA and SC in recurrence of Crohn's disease. Time to recurrence was longer in the IRA group by 4.4 years (95% CI: 3.1-5.8), P < 0.001. There was no difference between the incidence of postoperative complications (OR = 1.4., 95% CI 0.16-12.74) or the need for a permanent stoma between the two groups (OR = 2.75, 95% CI 0.78-9.71). Patients with two or more colonic segments involved were associated with lower re-operation rate in the IRA group, a difference which did not reach statistical significance (P = 0.177).

CONCLUSIONS

Both procedures were equally effective as treatment options for colonic Crohn's disease however, patients in the SC group exhibited recurrence earlier than those in the IRA group. The choice of operation is dependent on the extent of colonic disease, with a trend towards better outcomes with IRA for two or more colonic segments involved. Since no prospective randomised study has been undertaken, a clear view about which approach is more suitable for localised colonic Crohn's disease cannot be obtained.

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.

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.

[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.

Anti- and proinflammatory cytokines in the pathogenesis of tissue damage in Crohn's disease

Crohn's disease is a chronic inflammatory bowel disease of unknown origin. The understanding of the pathogenesis of inflammatory bowel diseases has been greatly advanced by manipulations of the immune system in mice using targeted disruptions of genes that encode specific anti- and proinflammatory cytokines, as well as T-cell subsets. The outcome of these experiments has implicated CD4+ lymphocytes and certain proinflammatory cytokines (tumour necrosis factor-alpha, interleukin-12) as playing a central role in the pathogenesis of mucosal inflammation in Crohn's disease. The present review focuses on these recent important immunological observations, and discusses several newly developed therapeutic strategies that are based either on blocking proinflammatory cytokines or on the administration of anti-inflammatory cytokines.

Audit of single-stage proctocolectomy for Crohn's disease: postoperative complications and recurrence

PURPOSE

This study was undertaken to review our overall experience of single-stage proctocolectomy for Crohn's disease.

METHODS

One hundred three patients who underwent single-stage proctocolectomy for Crohn's disease between 1958 and 1997 were reviewed. Factors affecting the incidence of recurrence were examined using a multivariate analysis.

RESULTS

Principal indications for proctocolectomy were chronic colitis (49 percent), acute colitis (37 percent), and anorectal disease (14 percent). The commonest postoperative complication was delayed perineal wound healing (n = 36; 35 percent), followed by intra-abdominal sepsis (17 percent) and stomal complications (15 percent). In 23 patients the perineal wound healed between three and six months after proctocolectomy, whereas in 13 patients the wound remained unhealed for more than six months. There were two hospital deaths (2 percent) caused by sepsis. The 5-year, 10-year, and 15-year cumulative reoperation rates for small-bowel recurrence were 13, 17, and 25 percent, respectively, after a median follow-up of 18.6 years. From a multivariate analysis, factors affecting reoperation rate for recurrence were gender (male; hazard ratio 2.4 vs. female; P = 0.03) and age at operation (< or =30 years; hazard ratio 2.6 vs. >30 years; P = 0.04). The following factors did not affect the reoperation rate: duration of symptoms, smoking habits, associated perforating disease, coexisting small-bowel disease, postoperative complications, and medical treatment.

CONCLUSIONS

Proctocolectomy for Crohn's disease is associated with a high incidence of complications, particularly delayed perineal wound healing. Proctocolectomy carries a low recurrence rate in the long term. However, young male patients are at high risk of recurrence.

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.

Surgical therapy for ulcerative colitis and Crohn's disease

Over the past 2 decades there has been considerable progress in the surgical management of inflammatory bowel disease. Crohn's disease is a chronic, nonspecific inflammatory disease of the gastrointestinal tract of unknown cause. It involves mainly the ileum, colon, and rectum, most often producing symptoms of obstruction or localized perforation with fistula. Although surgical treatment is palliative, operative excision in combination with strictureplasty, where appropriate, provides effective symptomatic relief and reasonable long-term benefit. Chronic ulcerative colitis is a diffuse inflammatory disease of the mucosal lining of the colon and rectum. Total removal of the colon and rectum provides a complete cure. Newer surgical alternatives, developed over the last 2 decades, have eliminated the need for a permanent ileostomy following definitive resection of the involved colon and rectum.

Long-term outcome of total colectomy and ileostomy for Crohn disease

BACKGROUND

This study was undertaken to review long-term results of total colectomy and end ileostomy for Crohn disease.

METHODS

Sixty-nine patients who underwent total colectomy and end ileostomy with an oversewn rectal stump for Crohn disease between 1962 and 1997 were reviewed. Postoperative complications, fate of the rectum or small-bowel recurrence, factors affecting complications and recurrence rates, and risk of rectal carcinoma are discussed.

RESULTS

Fourteen patients had an emergency colectomy. There were no operative or postoperative deaths. In all except five patients symptoms were rapidly relieved. The commonest postoperative complication was an intra-abdominal sepsis (12%). Only five patients (7%) underwent ileorectal anastomosis, of whom two required proctectomy later. Overall, 37 patients (54%) required proctectomy, with a median duration of 2 years. Sixteen patients (23%) developed small-bowel recurrence requiring surgery, with a median duration of 6.8 years. None of the following factors affected the proctectomy rate: sex, age at operation, duration of symptoms, smoking, perforating disease, coexisting small-bowel disease, preoperative proctitis, perianal disease, emergency operation, postoperative complications, or medical treatment. Youth was the only factor associated with a significantly higher reoperation rate for small-bowel recurrence. One patient developed an adenocarcinoma in a rectovaginal fistula, which was curatively resected at proctectomy.

CONCLUSIONS

Total colectomy and end ileostomy is a safe and effective procedure. However, a few patients underwent ileorectal anastomosis, and half of the patients required proctectomy. The small-bowel recurrence rate is low. Regular surveillance of the retained rectum is advised because of a small cancer risk.

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.

Short-chain fatty acids, lactate, and ammonia in ileorectal and ileal pouch contents: a model of cecal fermentation

Fecal concentrations of total short-chain fatty acids were normal in 16 patients with ileorectal anastomoses (mean +/- SEM, 99.7 +/- 10.3 mmol/L) and 28 patients with ileal pouch-anal anastomoses (138.8 +/- 8.5 mmol/L) and did not differ from those in 14 healthy noncolectomized controls (130.7 +/- 12.6 mmol/L). Acetate:propionate:butyrate:isobutyrate+valerate+isovalerate ratios were similar in the ileorectum (71:12:12:5%) and in the colorectum (66:14:13:7%) of healthy noncolectomized controls, whereas the concentration of acetate was increased at the expense of the polypeptide-derived isobutyrate, valerate, and isovalerate in the ileal pouch (77:12:11:1%). Ammonia was accordingly significantly diminished in ileal pouch contents (28.8 +/- 3.2 mmol/L vs 45.2 +/- 4.1 mmol/L in controls) in contrast to concentrations in ileorectal contents (36.2 +/- 5.3 mmol/L). Concentrations of lactate were normal and low. Twenty-four-hour productions of total short-chain fatty acids in 16.6% fecal homogenates from both groups of patients were normal. Addition of saccharides (eg, glucose, starch, pectin, ispaghula husk) increased the production of acetate, propionate, and butyrate and decreased the production of ammonia and isobutyrate, valerate, and isovalerate, which was increased in homogenates with albumin added. This pattern of substrate fermentation was similar in homogenates from ileal pouch, ileorectum, and control colorectum. In conclusion, the concentrations of short-chain fatty acids, lactate, and ammonia indicate that ileorectal fermentation resembles normal colorectal fermentation in noncolectomized healthy individuals, whereas the fermentation in ileal pouch contents seems to be more carbohydrate predominated.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors predictive of persistent or recurrent Crohn's disease in excluded rectal segments

The fate of the excluded rectal segment after surgery for Crohn's colitis remains poorly defined. To determine prognostic factors relating to the fate of the rectal segment, records of 47 patients who underwent creation of an excluded rectal segment were studied. Disease developed in 33 patients (70 percent) in the excluded rectal segment by five years; 24 patients (51 percent) had completion proctectomy by 2.4 years; and 9 patients (19 percent) retained a rectum with disease at a median follow-up period of five years (range, 2-13 years). At a median follow-up time of six years (range, 2-21 years), 14 patients were without clinical disease. The three groups were equivalent with respect to sex, duration of preoperative disease, indication for operation, distribution of disease, and histologic involvement of the proximal rectal margin. The median age of patients in the proctectomy group at diagnosis tended to be younger than that of patients with a retained excluded rectal segment (22, 30, and 31 years for patients having proctectomy, patients with a diseased excluded rectal segment, and patients with a normal excluded rectal segment, respectively). Neither initial involvement of the terminal ileum nor endoscopic inflammatory changes seen in the rectum predicted eventual disease of the excluded rectal segment. However, initial perianal disease complicating Crohn's colitis was predictive of persistent excluded rectal segment disease and often required proctectomy. Therefore, because the presence of perianal disease and Crohn's colitis predicts persistent or recurrent excluded rectal segment disease, primary total proctocolectomy or early completion proctectomy may be indicated in this subgroup of patients.