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Salimi-Jazi F, Rafeeqi T, Cunningham A, Park KT, Goyal A, Rosen MJ, Bruzoni M. Total colectomy in severe Crohn's colitis in children: Is permanent ileostomy necessary? JOURNAL OF PEDIATRIC SURGERY OPEN 2023; 3:100043. [DOI: 10.1016/j.yjpso.2023.100043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Kuroki H, Sugita A, Koganei K, Tatsumi K, Nakao E, Obara N. Postoperative results and complications of fecal diversion for anorectal Crohn's disease. Surg Today 2023; 53:386-392. [PMID: 35867163 PMCID: PMC9950159 DOI: 10.1007/s00595-022-02556-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 06/29/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Fecal diversion is a less-invasive technique that can alleviate symptoms in patients with refractory anorectal Crohn's disease. However, complications, including recurrence of residual anorectal Crohn's disease, may develop. We aimed to evaluate the postoperative results and complications associated with fecal diversion in patients with refractory anorectal Crohn's disease. METHODS We enrolled 1218 Crohn's disease patients who underwent laparotomy at our institute. We retrospectively analyzed the clinical features of 174 patients who underwent fecal diversion for refractory anorectal Crohn's disease, complications of the diverted colorectum, and the incidence and risk factors for proctectomy after fecal diversion. RESULTS After fecal diversion, 74% of patients showed improved symptoms. However, bowel continuity restoration was successful in four patients (2.2%), and anorectal Crohn's disease recurred in all patients. Seventeen patients developed cancer with a poor prognosis. The rate of conversion to proctectomy after fecal diversion was 41.3%, and the risk factors included rectal involvement (p = 0.02), loop-type stoma (p < 0.01), and the absence of treatment with biologics after fecal diversion (p = 0.03). CONCLUSION Fecal diversion for refractory anorectal Crohn's disease can improve clinical symptoms. Patients with rectal involvement or loop-type stoma have a greater risk of requiring proctectomy following fecal diversion. The administration of biologic may decrease the rate of proctectomy.
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Affiliation(s)
- Hirosuke Kuroki
- Department of Surgery for Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, 1-1, Mitsuzawanishicho Kanagawa-ku, Yokohama City, 221-0855, Japan.
| | - Akira Sugita
- grid.417366.10000 0004 0377 5418Department of Surgery for Inflammatory Bowel Disease, Yokohama Municipal Citizen’s Hospital, 1-1, Mitsuzawanishicho Kanagawa-ku, Yokohama City, 221-0855 Japan
| | - Kazutaka Koganei
- grid.417366.10000 0004 0377 5418Department of Surgery for Inflammatory Bowel Disease, Yokohama Municipal Citizen’s Hospital, 1-1, Mitsuzawanishicho Kanagawa-ku, Yokohama City, 221-0855 Japan
| | - Kenji Tatsumi
- grid.417366.10000 0004 0377 5418Department of Surgery for Inflammatory Bowel Disease, Yokohama Municipal Citizen’s Hospital, 1-1, Mitsuzawanishicho Kanagawa-ku, Yokohama City, 221-0855 Japan
| | - Eiichi Nakao
- grid.417366.10000 0004 0377 5418Department of Surgery for Inflammatory Bowel Disease, Yokohama Municipal Citizen’s Hospital, 1-1, Mitsuzawanishicho Kanagawa-ku, Yokohama City, 221-0855 Japan
| | - Nao Obara
- grid.417366.10000 0004 0377 5418Department of Surgery for Inflammatory Bowel Disease, Yokohama Municipal Citizen’s Hospital, 1-1, Mitsuzawanishicho Kanagawa-ku, Yokohama City, 221-0855 Japan
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Baelum JK, Qvist N, Ellebaek MB. Ileorectal anastomosis in patients with Crohn's disease. Postoperative complications and functional outcome-a systematic review. Colorectal Dis 2021; 23:2501-2514. [PMID: 34309170 DOI: 10.1111/codi.15839] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/27/2021] [Accepted: 07/20/2021] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
| | - Niels Qvist
- Surgical Department A, Odense University Hospital, Odense, Denmark
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Seifarth C, Lehmann KS, Holmer C, Pozios I. Healing of rectal advancement flaps for anal fistulas in patients with and without Crohn's disease: a retrospective cohort analysis. BMC Surg 2021; 21:283. [PMID: 34088303 PMCID: PMC8178918 DOI: 10.1186/s12893-021-01282-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/26/2021] [Indexed: 02/06/2023] Open
Abstract
Background Surgical closure of anal fistulas with rectal advancement flaps is an established standard method, but it has a high degree of healing failure in some cases. The aim of this study was to identify risk factors for anal fistula healing failure after advancement flap placement between patients with cryptoglandular fistulas and patients with Crohn’s disease (CD). Methods From January 2010 to October 2020, 155 rectal advancement flaps (CD patients = 55, non-CD patients = 100) were performed. Patients were entered into a prospective database, and healing rates were retrospectively analysed. Results The median follow-up period was 189 days (95% CI: 109–269). The overall complication rate was 5.8%. The total healing rate for all rectal advancement flaps was 56%. CD patients were younger (33 vs. 43 years, p < 0.001), more often female (76% vs. 30%, p < 0.001), were administered more immunosuppressant medication (65% vs. 5%, p < 0.001), and had more rectovaginal fistulas (29% vs. 8%, p = 0.001) and more protective stomas (49% vs. 2%, p < 0.001) than patients without CD. However, no difference in healing rate was noted between patients with or without CD (47% vs. 60%, p = 0.088). Conclusions Patients with anal fistulas with and without Crohn’s disease exhibit the same healing rate. Although patients with CD display different patient-specific characteristics, no independent factors for the occurrence of anal fistula healing failure could be determined. Trial registration Not applicable due to the retrospective study design.
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Affiliation(s)
- Claudia Seifarth
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Department of General-, Visceral- and Vascular Surgery, Berlin, Germany.
| | - Kai S Lehmann
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Department of General-, Visceral- and Vascular Surgery, Berlin, Germany
| | - Christoph Holmer
- Department of General and Visceral Surgery, St. Joseph Krankenhaus, Berlin, Germany
| | - Ioannis Pozios
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Department of General-, Visceral- and Vascular Surgery, Berlin, Germany
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5
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Salice M, Rizzello F, Sgambato D, Calabrese C, Manguso F, Laureti S, Rottoli M, Poggioli G, Gionchetti P. Long term remission after ileorectal anastomosis in Crohn's colitis. Dig Liver Dis 2021; 53:592-597. [PMID: 32616463 DOI: 10.1016/j.dld.2020.06.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Marco Salice
- IBD Unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Fernando Rizzello
- IBD Unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Dolores Sgambato
- Division of Hepato-Gastroenterology, Department of Clinical and Experimental Medicine, Second University of Naples, Via Pansini 5, 80131 Naples, Italy
| | - Carlo Calabrese
- IBD Unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Francesco Manguso
- Complex Operating Unit of Gastroenterology, AORN 'A. Cardarelli', Naples, Italy
| | - Silvio Laureti
- Surgical unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Matteo Rottoli
- Surgical unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Gilberto Poggioli
- Surgical unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Paolo Gionchetti
- IBD Unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy.
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McKenna NP, Bews KA, Habermann EB, Dozois EJ, Lightner AL, Mathis KL. What Factors Are Associated With the Eventual Need for an Ileostomy After Total Abdominal Colectomy and Ileosigmoid or Ileorectal Anastomosis for Crohn's Colitis in the Biologic Era? Dis Colon Rectum 2020; 63:504-513. [PMID: 32015288 DOI: 10.1097/dcr.0000000000001556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Outcomes after total abdominal colectomy with ileosigmoid or ileorectal anastomosis for Crohn's colitis and risk factors for requirement of a permanent ileostomy remain poorly understood, particularly in the biologic era. OBJECTIVE This study aimed to determine long-term ostomy-free survival after ileosigmoid or ileorectal anastomosis for Crohn's colitis and potential risk factors for requirement of an ileostomy. DESIGN This is a retrospective cohort study. SETTING This study was conducted at a single-institution IBD tertiary referral center. PATIENTS Patients diagnosed with Crohn's disease and undergoing ileosigmoid or ileorectal anastomosis between 2006 and 2018 were selected. MAIN OUTCOME MEASURE Long-term ostomy-free survival and hazard ratios of potential predictors of ileostomy requirement were the primary outcomes measured. RESULTS One hundred nine patients (56% female) underwent ileosigmoid or ileorectal anastomosis for Crohn's disease. The majority of surgical procedures were completed in 2 or 3 stages (53%). The indication for total abdominal colectomy was predominantly medically refractory disease (77%), with dysplasia the second leading indication (13%). At an overall mean follow-up of 3 years, 16 patients had undergone either proctectomy or diversion with the rectum in situ. This resulted in ostomy-free survival estimates at 5 and 10 years of 78% (95% CI, 68-90) and 58% (95% CI, 35-94). A positive distal microscopic margin was the only risk factor for later requirement of a permanent ileostomy (HR, 5.4; 95% CI, 1.7-17.2). LIMITATIONS This study is limited because it is a retrospective study at a tertiary referral center. CONCLUSIONS Long-term ostomy-free survival can be achieved in the majority of patients who undergo restoration of intestinal continuity after total abdominal colectomy for Crohn's colitis. A positive distal microscopic margin was independently associated with long-term anastomotic failure, and it should be accounted for when risk stratifying patients for postoperative prophylactic medical therapy. See Video Abstract at http://links.lww.com/DCR/B111. ¿QUÉ FACTORES ESTÁN ASOCIADOS CON LA EVENTUAL NECESIDAD DE UNA ILEOSTOMÍA DESPUÉS DE UNA COLECTOMÍA ABDOMINAL TOTAL Y UNA ANASTOMOSIS ILEOSIGMOIDEA O ILEORRECTAL PARA LA COLITIS DE CROHN EN LA ERA BIOLÓGICA?: Los resultados después de la colectomía abdominal total con anastomosis ileosigmoidea o ileorrectal para la colitis de Crohn y los factores de riesgo para el requerimiento de una ileostomía permanente siguen siendo poco conocidos, particularmente en la era biológica.Determinar la supervivencia a largo plazo sin ostomía después de una anastomosis ileosigmoidea o ileorrectal para la colitis de Crohn y los factores de riesgo potenciales para la necesidad de una ileostomía.Estudio de cohorte retrospectivo.Centro de referencia de tercel nivel para enfermedad inflamatoria intestinal de una sola institución.Pacientes diagnosticados con enfermedad de Crohn y sometidos a anastomosis ileosigmoidea o ileorrectal entre 2006 y 2018Supervivencia a largo plazo sin ostomías y cocientes de riesgo de predictores potenciales de requerimiento de ileostomía109 pacientes (56% mujeres) se sometieron a anastomosis ileosigmoidea o ileorrectal por enfermedad de Crohn. La mayoría de los procedimientos quirúrgicos se completaron en 2 o 3 etapas (53%). La indicación de colectomía abdominal total fue predominantemente enfermedad médicamente refractaria (77%), con displasia la segunda indicación principal (13%). En un seguimiento medio general de 3 años, 16 pacientes se habían sometido a una proctectomía o a una derivación con el recto in situ. Esto dio como resultado estimaciones de supervivencia sin ostomía a los 5 y 10 años de 78% (intervalo de confianza del 95%: 68-90) y 58% (intervalo de confianza del 95%: 35-94), respectivamente. Un margen microscópico distal positivo fue el único factor de riesgo para el requerimiento posterior de una ileostomía permanente (razón de riesgo: 5.4; intervalo de confianza del 95%, 1.7-17.2).Estudio retrospectivo en un centro de referencia de tercer nivel.La supervivencia a largo plazo sin ostomía se puede lograr en la mayoría de los pacientes que se someten a la restauración de la continuidad intestinal después de la colectomía abdominal total por colitis de Crohn. Un margen microscópico distal positivo se asoció de forma independiente con la insuficiencia anastomótica a largo plazo, y debe tenerse en cuenta cuando se trata de pacientes con estratificación de riesgo para el tratamiento médico profiláctico postoperatorio. Consulte Video Resumen en http://links.lww.com/DCR/B111.
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Affiliation(s)
- Nicholas P McKenna
- Department of Surgery, Mayo Clinic, Rochester, Minnesota.,The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Katherine A Bews
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, Minnesota.,The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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Müller C, Bergmann M, Stift A, Argeny S, Speake D, Unger L, Riss S. Restoration of intestinal continuity after stoma formation for Crohn’s disease in the era of biological therapy. Wien Klin Wochenschr 2020; 132:12-18. [PMID: 31915925 PMCID: PMC6978468 DOI: 10.1007/s00508-019-01586-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/19/2019] [Indexed: 01/16/2023]
Abstract
Background The rate of restoration of intestinal continuity after colonic resection and stoma creation in patients with Crohn’s disease has not been well-documented in the era of biologics. Thus, the incidence of restoration of intestinal continuity since the introduction of biological drugs was assessed. Methods Consecutive patients (n = 43) who underwent colonic resection with ileostomy or colostomy formation for Crohn’s disease at a single tertiary referral center between 2002 and 2014 were identified. Data from individual chart review were analyzed retrospectively. Patients were personally contacted for follow-up. Results Of the 43 patients 8 (18.4%) had a proctectomy leaving 35 patients (81.4%) with the rectum preserved. Of the 30 patients qualifying for final analysis restoration of bowel continuity was finally achieved in 10 patients (33.3%). Permanent stoma rates were comparable in the group of patients with and without biological therapy after surgery (64.3% vs. 60%). The median follow-up period was 7 years (range 3–15 years). Of the patients 20 suffered from perianal disease involvement (66.7%), which was associated with a higher rate of permanent stoma (n = 16/20, 80%) in contrast to patients without perianal disease (n = 4/10, 40%, p = 0.045). Conclusion The overall incidence of stoma formation was low for patients with Crohn’s disease; however, once a stoma is created the chance of ending up with a permanent stoma is high even in the era of biologics. Despite the use of new therapeutic agents perianal disease increases the risk of a permanent stoma.
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Affiliation(s)
- Catharina Müller
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Michael Bergmann
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Anton Stift
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Stanislaus Argeny
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Doug Speake
- Department of Surgery, Western General Hospital, Crewe Road South, EH4 2XU, Edinburgh, UK
| | - Lukas Unger
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Stefan Riss
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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Risk factors for proctectomy in consecutive Crohn's colitis surgical patients in a reference colorectal centre. Int J Colorectal Dis 2019; 34:1401-1406. [PMID: 31254067 DOI: 10.1007/s00384-019-03337-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Crohn's colitis carries a risk for permanent stoma with extirpation of the rectum. We aimed to estimate the proctectomy rate and identify risk factors for proctectomy in patients with Crohn's colitis. METHODS For this study, we retrospectively reviewed data from consecutive patients with Crohn's disease (CD) affecting the colon or anorectal region undergoing bowel resection in a reference colorectal centre between 2006 and 2016. The cumulative risk for proctectomy was calculated using the Kaplan-Meier curve. We used univariate and multivariate logistic regression analyses to determine independent risk factors for proctectomy. Outcomes after proctectomy concerning reoperation frequency and perineal wound healing are also described. RESULTS In total, this study included 125 patients. Proctectomy was performed in 36 patients (28.8%), of whom 14 patients (38.9%) experienced perineal wound healing problems. The rates of proctectomy were 5.6% and 32.0% 10 and 20 years after CD diagnosis, respectively. Female gender (odds ratio (OR) 3.375, 95% confidence interval (CI) 1.304-8.733, P = 0.012), disease duration (OR 1.067, 95% CI 1.011-1.126, P = 0.018) and history of perianal disease (OR 3.160, 95% CI 1.215-8.219, P = 0.018) were independent risk factors for a proctectomy procedure, whereas thiopurine medication (OR 0.170, 95% CI 0.060-0.486, P = 0.001) was an independent protective factor for proctectomy. CONCLUSIONS The duration of Crohn's disease, female gender and a history of perianal disease were significant risk factors for a proctectomy procedure. Future research should examine whether immunosuppressive and biological medications reduce the risk for proctectomy.
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Lopez NE, Zaghyian K, Fleshner P. Is There a Role for Ileal Pouch Anal Anastomosis in Crohn's Disease? Clin Colon Rectal Surg 2019; 32:280-290. [PMID: 31275075 DOI: 10.1055/s-0039-1683917] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Traditionally, surgical interventions for colonic Crohn's disease (CD) have been limited to total abdominal colectomy and ileorectal anastomosis, or total proctocolectomy with end ileostomy if there is rectal involvement. However, improved understandings of the biology of CD, as well as the development of biologic therapies, have enabled more limited resections. Here, we review the indications for, and limitations of, specific procedures aiming to preserve intestinal continuity in colonic CD.
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Affiliation(s)
- Nicole E Lopez
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Karen Zaghyian
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Abstract
This article provides a structured approach to the technical aspects of reoperative surgery for Crohn's disease. Specific indications for surgery including repeat ileocolic resection, Crohn's complications of ileal pouch anal anastomosis and continent ileostomy, completion proctectomy, and the role of small bowel transplant will be discussed.
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Affiliation(s)
- Jennifer A Leinicke
- Department of Surgery-Colorectal, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - David W Dietz
- Department of Surgery-Colorectal, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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Fichera A, Schlottmann F, Krane M, Bernier G, Lange E. Role of surgery in the management of Crohn's disease. Curr Probl Surg 2018; 55:162-187. [DOI: 10.1067/j.cpsurg.2018.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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12
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Scaringi S, Di Bella A, Boni L, Giudici F, Di Martino C, Zambonin D, Ficari F. New perspectives on the long-term outcome of segmental colectomy for Crohn's colitis: an observational study on 200 patients. Int J Colorectal Dis 2018; 33:479-485. [PMID: 29511841 DOI: 10.1007/s00384-018-2998-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Surgical management of Crohn's colitis represents one of the most complex situations in colorectal surgery. Segmental colectomy (SC) and total abdominal colectomy with ileorectal anastomosis (TAC-IRA) are the most common procedures, but there are few available data on their long-term outcome. The aim of the present study was to analyze the long-term outcome of patients who underwent segmental colectomy for Crohn's colitis, with regard to the risk for total abdominal colectomy. METHODS In this observational, monocentric, retrospective analysis, we analyzed patients who received a segmental colectomy for Crohn's colitis at our institution. The database was updated by asking patients to complete a questionnaire by telephone or at the outpatient clinic. Only patients followed up at our Hospital were included. Patients were followed up by a specialized multidisciplinary team (IBD Unit). The primary endpoint was the interval between segmental colectomy and, when performed, total abdominal colectomy. RESULTS Between 1973 and 2014, 200 patients underwent segmental colectomy for Crohn's colitis. The median follow-up was 13.5 years (interquartile range [IQR] 7.8-21.5). Overall, 62 patients (31%) had a surgical recurrence, of these, 42 (21%) received total abdominal colectomy. At multivariate analysis, the presence of ≥ 3 sites (HR = 2.47; 95% CI 1.22-5.00; p = 0.018) and perianal disease (HR = 3.23; 95% CI 1.29-8.07; p = 0.006) proved to be risk factors for total abdominal colectomy. CONCLUSIONS The risk for surgical recurrence after SC for Crohn's colitis is acceptable. We recommend a bowel-sparing policy for the treatment of Crohn's colitis in any case in which the extent of the disease at the moment of surgery makes the conservative approach achievable.
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Affiliation(s)
- Stefano Scaringi
- Digestive Surgery Unit - IBD Unit, Careggi University Hospital, Pad. 16, 1st floor, room 140-141, Largo Brambilla 3, 50134, Florence, Italy.
| | - Annamaria Di Bella
- Digestive Surgery Unit - IBD Unit, Careggi University Hospital, Pad. 16, 1st floor, room 140-141, Largo Brambilla 3, 50134, Florence, Italy
| | - Luca Boni
- Digestive Surgery Unit - IBD Unit, Careggi University Hospital, Pad. 16, 1st floor, room 140-141, Largo Brambilla 3, 50134, Florence, Italy
| | - Francesco Giudici
- Digestive Surgery Unit - IBD Unit, Careggi University Hospital, Pad. 16, 1st floor, room 140-141, Largo Brambilla 3, 50134, Florence, Italy
| | - Carmela Di Martino
- Digestive Surgery Unit - IBD Unit, Careggi University Hospital, Pad. 16, 1st floor, room 140-141, Largo Brambilla 3, 50134, Florence, Italy
| | - Daniela Zambonin
- Digestive Surgery Unit - IBD Unit, Careggi University Hospital, Pad. 16, 1st floor, room 140-141, Largo Brambilla 3, 50134, Florence, Italy
| | - Ferdinando Ficari
- Digestive Surgery Unit - IBD Unit, Careggi University Hospital, Pad. 16, 1st floor, room 140-141, Largo Brambilla 3, 50134, Florence, Italy
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Angriman I, Pirozzolo G, Bardini R, Cavallin F, Castoro C, Scarpa M. A systematic review of segmental vs subtotal colectomy and subtotal colectomy vs total proctocolectomy for colonic Crohn's disease. Colorectal Dis 2017; 19:e279-e287. [PMID: 28614620 DOI: 10.1111/codi.13769] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 03/13/2017] [Indexed: 12/12/2022]
Abstract
AIM Surgical management of colonic Crohn's disease (CD) is still unclear because different procedures can be adopted. The choice of operation is dependent on the involvement of colonic disease but the advantages and disadvantages of the extent of resection are still debated. METHOD The aim of the present study was to evaluate the differences in short-term and long-term outcomes of adult patients with colonic CD who underwent either subtotal colectomy and ileorectal anastomosis (STC) or segmental colectomy (SC) or total proctocolectomy and end ileostomy (TPC). Studies published between 1984 and 2012 including comparisons of STC vs SC and of STC vs TPC were selected. The study end-points were overall and surgical recurrence, postoperative morbidity and incidence of permanent stoma. Fixed effect models were used to evaluate the study outcomes. RESULTS Eleven studies, consisting of a total of 1436 patients (510 STC, 500 SC and 426 TPC), were included. Analysis of the data showed no significant difference between STC and SC in terms of overall and surgical recurrence of CD. In contrast, STC showed a higher risk of overall and surgical recurrence of CD than TPC (OR 3.53, 95% CI 2.45-5.10, P < 0.0001; OR 3.52, 95% CI 2.27-5.44, P < 0.0001, respectively). SC had a higher risk of postoperative complications compared to STC, and STC had a lower risk of complications than TPC (OR 2.84, 95% CI 1.16-6.96, P < 0.02; OR 0.19, 95% CI 0.09-0.38, P < 0.0001, respectively). SC resulted in a lower risk of permanent stoma than STC (OR 0.52, 95% CI 0.35-0.77). CONCLUSION All three procedures were equally effective as treatment options for colonic CD and the choice of operation remains intrinsically dependent on the extent of colonic disease. However, patients in the TPC group showed a lower recurrence risk than those in the STC group. Moreover, SC had a higher risk of postoperative complications but a lower risk of permanent stoma. These data should be taken into account when deciding surgical strategies and when informing patients about postoperative risks.
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Affiliation(s)
- I Angriman
- Department of Surgical, Gastroenterological and Oncological Sciences, University of Padova, Padova, Italy
| | - G Pirozzolo
- Department of Surgical, Gastroenterological and Oncological Sciences, University of Padova, Padova, Italy
| | - R Bardini
- Department of Surgical, Gastroenterological and Oncological Sciences, University of Padova, Padova, Italy
| | - F Cavallin
- Oesophageal and Digestive Tract Surgical Unit, Veneto Institute of Oncology IOV-IRCCS, Padova, Italy
| | - C Castoro
- Oesophageal and Digestive Tract Surgical Unit, Veneto Institute of Oncology IOV-IRCCS, Padova, Italy
| | - M Scarpa
- Oesophageal and Digestive Tract Surgical Unit, Veneto Institute of Oncology IOV-IRCCS, Padova, Italy
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Abstract
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.
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Lee JL, Yu CS, Lim SB, Park IJ, Yoon YS, Kim CW, Yang SK, Kim JC. Surgical Treatment of Crohn Colitis Involving More Than 2 Colonic Segments: Long-Term Outcomes From a Single Institution. Medicine (Baltimore) 2016; 95:e3793. [PMID: 27258512 PMCID: PMC4900720 DOI: 10.1097/md.0000000000003793] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Jong Lyul Lee
- From the Department of Surgery, Division of Colon and Rectal Surgery (JLL, CSY, S-BL, IJP, YSY, CWK, JCK); and Department of Gastroenterology (S-KY), University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Abstract
There is no cure for Crohn disease. Newer treatments, such as biological therapy, have led to an improved quality of life. This article focuses on the surgical management of Crohn disease of the colon, rectum, and anus. Restorative and nonrestorative surgical options for colonic Crohn disease are discussed. Treatment options for perianal Crohn disease are also reviewed.
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Affiliation(s)
- William J Harb
- The Colorectal Center, 2011 Church Street, Suite 703, Nashville, TN 37203, USA.
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Seifarth C, Kreis ME, Gröne J. Indications and Specific Surgical Techniques in Crohn's Disease. VISZERALMEDIZIN 2015; 31:273-9. [PMID: 26557836 PMCID: PMC4608647 DOI: 10.1159/000438955] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Crohn's disease (CD) as one of the major entities of chronic inflammatory bowel diseases can affect all segments of the gastrointestinal tract but occurs most often in the small bowel, the terminal ileum, the colon, and the rectum. Typical symptoms include tiredness, lower abdominal pain, fever, and diarrhea, which are initially treated by conservative measures. Most patients will eventually develop complications such as fistulas, abscesses, or strictures. Surgery is often unavoidable in these cases. Methods This review considers studies on the treatment of CD, published from 1979 up to now. The literature regarding the course, complications, and surgical therapy of CD was reviewed. Searches were performed in PubMed, using the following key words: CD, surgery, immunosuppression, guidelines, malnutrition as well as appropriate sub-items. In most cases the literature is limited to detailed information on specific therapeutic or diagnostic topics. Moreover, many studies are designed retrospectively and with a small number of patients. Additionally, our long-standing experience with patients suffering from CD is taken into consideration in this review. Results There is a wide variety of indications for surgery in CD which includes complications like strictures, fistulas and abscess formation, neoplasia, or refractoriness to medical therapy. The risk of developing complications is about 33% after 5 years, and 50% after 20 years. Furthermore, one-third of CD patients need surgical therapy within the first 5 years of diagnosis. The treatment requires close cooperation between gastroenterologists and surgeons. When indicated, surgery should be performed in a ‘conservative’ fashion, i.e. as limited as possible, in order to achieve the required result and to avoid small bowel syndrome. Conclusion This article provides a complete overview of indications and specific surgical treatment in patients with CD. Surgery is typically indicated when complications of CD occur. An interdisciplinary collaboration is necessary in order to ensure optimal indications and timing of surgery. This is of paramount importance to achieve the ultimate goal, i.e. a good quality of life of the patients.
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Affiliation(s)
- Claudia Seifarth
- Department of General, Visceral- and Vascular Surgery, Charité - University Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Martin E Kreis
- Department of General, Visceral- and Vascular Surgery, Charité - University Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Jörn Gröne
- Department of General, Visceral- and Vascular Surgery, Charité - University Medicine, Campus Benjamin Franklin, Berlin, Germany
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Duclos J, Lefevre JH, Lefrançois M, Lupinacci R, Shields C, Chafai N, Tiret E, Parc Y. Immediate outcome, long-term function and quality of life after extended colectomy with ileorectal or ileosigmoid anastomosis. Colorectal Dis 2014; 16:O288-96. [PMID: 24428330 DOI: 10.1111/codi.12558] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 11/29/2013] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- J Duclos
- Department of Digestive Surgery, Saint-Antoine Hospital, University Pierre and Marie Curie, Paris VI, Paris, France
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Abstract
Colonic Crohn disease is a complicated disease entity that requires a multidisciplinary effort on the part of the surgeon, gastroenterologist, and pathologist. Crohn disease affects ∼500,000 people in North America with nearly 300,000 people suffering from colonic manifestations. This represents a significant portion of the patient population in the typical colorectal surgeon's practice. As such, an intimate understanding of the disease process, presentation, and treatment options is imperative. In this article, the authors review the clinical manifestations, diagnosis, and medical and surgical treatment options with a focus on current strategies for surgical management.
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Affiliation(s)
- Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Charles M Friel
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
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20
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Abstract
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.
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21
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Carlson RM, Roberts PL. Abdominal Surgery for Crohn's Disease—A Surgical Perspective. SEMINARS IN COLON AND RECTAL SURGERY 2012. [DOI: 10.1053/j.scrs.2012.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
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%.
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23
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The role of primary surgical procedure in maintaining intestinal continuity for patients with Crohn's colitis. Ann Surg 2011; 253:1130-5. [PMID: 21394010 DOI: 10.1097/sla.0b013e318212b1a4] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study evaluates surgical procedures for Crohn's colitis. The risk of recurrence and how it interacts with future avoidance of permanent stoma and quality of life (QoL) is studied. BACKGROUND Segmental and subtotal colectomy are widely used surgical options in isolated Crohn's colitis. It is not clear which procedure offers the best outcomes. METHODS Patients undergoing index resection for isolated colonic Crohn's disease (CD) from 1995 to 2009, were identified from a prospectively maintained CD database. Patients were categorized into subtotal colectomy or segmental groups. Demographics, disease characteristics, operative details, morbidity, stoma formation, recurrence requiring surgery and QoL data were extracted. Recurrence and stoma free survival was calculated for each group and independent risk factors for recurrence and stoma formation identified. RESULTS One hundred and eight patients (49 segmental, 59 subtotal) underwent primary colectomy with anastomosis. Segmental colectomy patients had significantly reduced recurrence free survival (P = 0.032) but not stoma free survival P = 0.62 on univariate analysis. On multivariate analysis, the presence of perianal sepsis (P = 0.032) and >1 medical comorbidity (P = 0.01), but not segmental colectomy, were associated with reduced SFS. There was no difference in Cleveland Global Quality of Life (P = 0.88), or Short Form Inflammatory Bowel Disease Questionnaire scores between groups (P = 0.92). CONCLUSIONS Using a strictly defined cohort of patients, we were unable to identify segmental resection as an independent risk factor for recurrence or stoma formation and no reduction in QoL scores to suggest an adverse effect of recurrence was observed. Segmental colectomy affords good function, and our data supports the practice of a conservative approach with anastomosis in anatomically linked CD.
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Sciaudone G, Pellino G, Riegler G, Selvaggi F. Infliximab in Drug-Naïve Patients with Failed Ileorectal Anastomosis for Crohn’s Disease: A New Chance for Sparing the Rectum. Eur Surg Res 2011; 46:163-8. [DOI: 10.1159/000324398] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 01/17/2011] [Indexed: 12/18/2022]
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Averboukh F, Kariv Y. Ileal Pouch Rectal Anastomosis: Technique, Indications, and Outcomes. SEMINARS IN COLON AND RECTAL SURGERY 2009. [DOI: 10.1053/j.scrs.2009.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Kariv Y, Remzi FH, Strong SA, Hammel JP, Preen M, Fazio VW. Ileal Pouch Rectal Anastomosis: A Viable Alternative to Permanent Ileostomy in Crohn's Proctocolitis Patients. J Am Coll Surg 2009; 208:390-9. [DOI: 10.1016/j.jamcollsurg.2008.10.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 10/02/2008] [Accepted: 10/02/2008] [Indexed: 12/14/2022]
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27
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Anastomosis ileoanal con reservorio en pacientes con enfermedad de Crohn. Estado actual. Cir Esp 2009; 85:69-75. [DOI: 10.1016/j.ciresp.2008.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Accepted: 09/12/2008] [Indexed: 01/26/2023]
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Colon, Rectum, and Anus. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Fichera A, McCormack R, Rubin MA, Hurst RD, Michelassi F. Long-term outcome of surgically treated Crohn's colitis: a prospective study. Dis Colon Rectum 2005; 48:963-9. [PMID: 15785882 DOI: 10.1007/s10350-004-0906-3] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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30
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Champault A, Benoist S, Alvès A, Panis Y. [Surgical therapy for Crohn's disease of the colon and rectum]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28:882-92. [PMID: 15523226 DOI: 10.1016/s0399-8320(04)95153-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Affiliation(s)
- Axèle Champault
- Service de Chirurgie Digestive, Hôpital Lariboisière, 2, Rue Ambroise Paré, 75475 Paris Cedex 10, France
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31
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Bullen TF, Hershman MJ. Surgery for inflammatory bowel disease. HOSPITAL MEDICINE (LONDON, ENGLAND : 1998) 2003; 64:719-23. [PMID: 14702783 DOI: 10.12968/hosp.2003.64.12.2363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
Ulcerative colitis is potentially cured by total excision of the colon and rectum. Crohn's disease is an unremitting condition in which operations are frequently multiple and in which the minimum amount of bowel possible should be excised.
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Affiliation(s)
- Timothy F Bullen
- MASTER Unit, Royal Liverpool University Hospital, Liverpool L7 8XP
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32
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Delaney CP, Kiran RP, Senagore AJ, O'Brien-Ermlich B, Church J, Hull TL, Remzi FH, Fazio VW. Quality of life improves within 30 days of surgery for Crohn's disease. J Am Coll Surg 2003; 196:714-21. [PMID: 12742203 DOI: 10.1016/s1072-7515(03)00131-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The effect of surgery on quality of life (QOL) in the early postoperative period is important in Crohn's disease because of the multiple surgical procedures that patients undergo and the acute QOL benefits that might occur as a result of modifications of medical treatment. Earlier studies of the effect of surgery on QOL have been retrospective and assessed changes 3 to 24 months after surgery. This study prospectively assesses the effect of surgery on QOL in the early postoperative period. STUDY DESIGN Patients requiring surgical management of sequelae of Crohn's disease were obtained from a prospectively entered database including data on QOL. Preoperative and 30-day postoperative QOL were determined in 82 patients using Cleveland Global Quality of Life (CGQL) scores (range from 0 [worst] to 10 [best possible] QOL). Preoperative and postoperative scores were compared using a paired t-test to determine the significance of any change in QOL after surgery. The effect of other variables on change in QOL after surgery was assessed using the t-test or analysis of variance. Multifactor analysis of variance was used to assess the effect of several independent variables. RESULTS Eighty-two patients (41 women) of 142 patients who had had surgery (58%) had complete preoperative and 30-day postoperative scores. The incidence of complications was 23% (11% were major). There was a significant improvement in QOL 30 days after surgery as measured by CGQL (0.6 +/- 0.2 preoperative to 0.7 +/- 0.2 postoperative; mean +/- SD; p < 0.001). The mean preoperative CGQL was 0.56 +/- 0.24 and the mean improvement was 0.11 +/- 0.20 toward a better QOL. Female patients (p < 0.05) and those who did not develop complications within 30 days of surgery (p < 0.05) had a significantly greater improvement in CGQL after surgery than other groups. No other factor was predictive of improved outcomes. CONCLUSIONS QOL as measured by CGQL improves early after surgery (30 days postoperatively). Improvement in CGQL is greater in female patients and patients who do not develop complications in the postoperative period. It is not affected by other patient characteristics, nature of disease, indication, or procedure performed. Most patients who undergo surgery for Crohn's disease feel that surgery has helped them and would undergo surgery again.
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Affiliation(s)
- Conor P Delaney
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Elton C, Makin G, Hitos K, Cohen CRG. Mortality, morbidity and functional outcome after ileorectal anastomosis. Br J Surg 2003; 90:59-65. [PMID: 12520576 DOI: 10.1002/bjs.4005] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- C Elton
- Department of Surgery, St Mark's Hospital, Harrow, UK.
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Martel P, Betton PO, Gallot D, Malafosse M. Crohn's colitis: experience with segmental resections; results in a series of 84 patients. J Am Coll Surg 2002; 194:448-53. [PMID: 11949750 DOI: 10.1016/s1072-7515(02)01122-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Philippe Martel
- Department of Digestive Surgery, Bichat Hospital, Paris, France
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Cattan P, Bonhomme N, Panis Y, Lémann M, Coffin B, Bouhnik Y, Allez M, Sarfati E, Valleur P. Fate of the rectum in patients undergoing total colectomy for Crohn's disease. Br J Surg 2002; 89:454-9. [PMID: 11952587 DOI: 10.1046/j.0007-1323.2001.02053.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- P Cattan
- Department of Digestive Surgery, Hôpital Saint-Louis, Paris, France.
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Mylonakis E, Allan RN, Keighley MR. How does pouch construction for a final diagnosis of Crohn's disease compare with ileoproctostomy for established Crohn's proctocolitis? Dis Colon Rectum 2001; 44:1137-42; discussion 1142-3. [PMID: 11535853 DOI: 10.1007/bf02234634] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE There is a difference of opinion concerning the role of ileal pouch-anal anastomosis in Crohn's disease, even in the absence of small-bowel or perianal disease. One view is that ileal pouch-anal anastomosis should never be entertained, the other is that ileal pouch-anal anastomosis, like ileoproctostomy, can be justified sometimes, because it allows young people a period of stoma-free life. The aim of this study was to examine the outcome of ileal pouch-anal anastomosis and to contrast it with ileoproctostomy in patients with Crohn's disease without small-bowel or perianal disease. METHODS Ileal pouch-anal anastomosis was performed in 23 patients with Crohn's disease (12 of whom had evidence of Crohn's disease at the time of operation and 11 who were eventually found to have Crohn's disease as a result of complications) and ileoproctostomy in 35. Patients were matched for age, gender, follow-up, and medication, but all ileoproctostomy cases had relative rectal sparing. Thus, the groups were not comparable and the reasons for ileal pouch-anal anastomosis and ileoproctostomy were therefore quite different. RESULTS The outcome in ileal pouch-anal anastomosis at a mean follow-up of 10.2 years was pouch excision, 11 (47.8 percent); proximal stoma, 1 (4.3 percent; patient preference); average small-bowel resection, 65 cm; persistent perineal sinus, 8 of 11 having pouch excision (73 percent); and mean time in hospital, 37 (range, 8-108) days. Of those in circuit having ileal pouch-anal anastomosis (n = 12), 24-hour bowel frequency was 6, with no incontinence or urgency, but 6 (50 percent) were on medication. When ileal pouch-anal anastomosis was done for Crohn's disease in the resection specimen, only 4 of 12 (33 percent) were excised compared with 7 of 11 (64 percent) in whom the diagnosis was made as a result of complications. The outcome in ileoproctostomy at a mean follow-up of 10.9 years was rectal excision in 3 (8 percent), proximal stoma in 1 (3 percent), average small-bowel resection was 15 cm, persistent perineal sinus in 1 (3 percent), and time in hospital was 21 (range, 8-36) days. Of those in circuit (n = 32), 24-hour bowel frequency was 5, 2 had incontinence, 3 had urgency, and 12 (36 percent) were taking medication. CONCLUSIONS These results indicate that the overall outcome of ileal pouch-anal anastomosis is inferior to that of ileoproctostomy, especially if Crohn's disease was diagnosed as a result of complications. Nevertheless, the functional results of those with a successful outcome are comparable.
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Affiliation(s)
- E Mylonakis
- University Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom
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Abstract
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.
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Affiliation(s)
- O Bernell
- Departments of Surgery and Gastroenterology, Huddinge University Hospital, Sweden
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Abstract
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.
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Affiliation(s)
- T S Guy
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, USA
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Martel P, Betton PO, Gallot D, Sezeur A, Malafosse M. [Surgical treatment of Crohn's disease of the large intestine: do rectal complications influence the results of ileorectal anastomosis?]. ANNALES DE CHIRURGIE 2000; 125:547-51. [PMID: 10986766 DOI: 10.1016/s0003-3944(00)00239-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- P Martel
- Service de chirurgie digestive, hôpital Bichat, Paris, France
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Yamamoto T, Allan RN, Keighley MR. Audit of single-stage proctocolectomy for Crohn's disease: postoperative complications and recurrence. Dis Colon Rectum 2000; 43:249-56. [PMID: 10696900 DOI: 10.1007/bf02236990] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- T Yamamoto
- University Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom
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Yamamoto T, Keighley MR. Proctocolectomy is associated with a higher complication rate but carries a lower recurrence rate than total colectomy and ileorectal anastomosis in Crohn colitis. Scand J Gastroenterol 1999; 34:1212-5. [PMID: 10636068 DOI: 10.1080/003655299750024724] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- T Yamamoto
- University Dept. of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
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Abstract
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.
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Affiliation(s)
- T Yamamoto
- University Dept. of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
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Rieger N, Collopy B, Fink R, Mackay J, Woods R, Keck J. Total colectomy for Crohn's disease. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1999; 69:28-30. [PMID: 9932916 DOI: 10.1046/j.1440-1622.1999.01486.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- N Rieger
- Department of Colon and Rectal Surgery, St Vincent's Hospital, Fitzroy, Victoria, Australia.
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Fazio VW, Wu JS, Lavery IC. Repeat ileal pouch-anal anastomosis to salvage septic complications of pelvic pouches: clinical outcome and quality of life assessment. Ann Surg 1998; 228:588-97. [PMID: 9790348 PMCID: PMC1191541 DOI: 10.1097/00000658-199810000-00015] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate the outcome of repeat ileal pouch-anal anastomosis (IPAA) for septic complications of pelvic pouch surgery; to assess the relationship between diagnosis and outcome; to assess quality of life after surgery. SUMMARY BACKGROUND DATA Pelvic and perineal sepsis due to ileal pouch-anal anastomotic leaks frequently results in pouch loss. Many surgeons believe that pelvic sepsis and/or dense pelvic fibrosis makes salvage surgery unsafe or that pouches salvaged under these circumstances may not function well. As a result, there are few studies of pouch salvage procedures for septic indications. METHODS The authors reviewed records of Cleveland Clinic Foundation patients who had undergone repeat IPAA surgery after septic complications from previous pelvic pouch surgery and who had completed at least 6 months of follow-up. Final diagnoses included ulcerative colitis (n = 22), Crohn's disease (n = 10), indeterminate colitis (n = 1), and familial polyposis (n = 2). Patients with functioning pouches were interviewed about functional problems and quality of life using an in-house questionnaire and the validated SF-36 Health Survey. RESULTS Of 35 patients, 30 (86%) had a functioning pouch 6 months after repeat IPAA. In 4 patients, complications led to pouch removal or fecal diversion. One patient declined stoma closure. Of the patients with mucosal ulcerative colitis (MUC), 95% (21/22) had a functioning pouch 6 months after surgery. For patients with Crohn's disease (CD) 60% (6/10) have maintained a functioning pouch. Of the 30 patients with functioning pouches, 17 (57%) rated their quality of life as either "good" or "excellent," the remaining 13 (43%) selected "fair" or "poor." All said they would choose repeat IPAA surgery again. An SF-36 Health Survey completed by all patients with a functioning pouch at follow-up showed a mean physical component scale of 46.4 and a mean mental component scale of 47.6, scores well within the normal limit. CONCLUSIONS Repeat IPAA can often salvage pelvic pouches in patients with MUC who suffer major chronic perianastomotic and pelvic sepsis. Patients who had successful repeat IPAA surgery often report functional problems but would still choose to have the surgery again. For patients with CD, ultimate pouch excision or fecal diversion have been required in 40% indicating a guarded prognosis for these patients. Data on the success of the procedure for patients with indeterminate colitis and familial adenomatous polyposis were inconclusive because of small sample sizes.
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Affiliation(s)
- V W Fazio
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio 44195, USA
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Abstract
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.
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Affiliation(s)
- J J Murray
- Department of Colon and Rectal Surgery, Lahey Hitchcock Medical Center, Burlington, MA 01805, USA
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Pastore RL, Wolff BG, Hodge D. Total abdominal colectomy and ileorectal anastomosis for inflammatory bowel disease. Dis Colon Rectum 1997; 40:1455-64. [PMID: 9407985 DOI: 10.1007/bf02070712] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE This retrospective study assesses the results of total colectomy and ileorectostomy for inflammatory bowel disease. METHODS Between January 1974 and December 1990, 90 patients underwent total colectomy and ileorectal anastomosis for chronic ulcerative colitis (n = 48) or Crohn's colitis (n = 42) at the Mayo Clinic. Patients' records were reviewed retrospectively. Long-term results were assessed by chart reviews and postal questionnaires. Conversion to a permanent ileostomy, with or without proctectomy, was considered a failure of the procedure. The Kaplan-Meier method was used to estimate survivorship free of failure. The log-rank test was used to compare survivorship curves. Ninety-five percent confidence intervals were calculated at selected time points. P values < 0.05 were considered to be statistically significant. RESULTS The main indication for surgery was refractory chronic disease. There were no immediate postoperative deaths. The anastomotic leakage rate was 4.4 percent, and small-bowel obstruction occurred in 15.6 percent. At the time of follow-up (mean, 6.5 +/- 4.8 years), 46 patients (58.9 percent) had recurrence or exacerbation of the disease. This was the most common indication for subsequent proctectomy/permanent ileostomy in the follow-up period. There were 8 failures in 48 patients with ulcerative colitis (16.7 percent) and 11 failures in 42 patients with Crohn's disease (26.2 percent), although this difference was not statistically significant. Cumulative probability of having a functioning ileorectal anastomosis at five years was 84.2 percent (95 percent confidence interval, 71-95.9 percent) for ulcerative colitis and 73.8 percent (95 percent confidence interval, 58.6-88.6 percent) for Crohn's disease. In the latter group, females showed a significantly lower cumulative probability of having a functioning ileorectal anastomosis (females, 63.4 percent; males, 92.3 percent; P = 0.04). Crohn's patients 36 years of age or younger also showed a lower probability of success (patients < or = 36 years, 57 percent; patients > 36 years, 93.8 percent; P = 0.03). In the group with chronic ulcerative colitis, younger patients also seemed to require additional surgery more frequently; however, this difference was not statistically significant. Previous duration of symptoms, with mild or moderate disease in a distensible rectum, had no effect on results in either disease group. Functional results were acceptable in 63.6 and 87.5 percent of patients with Crohn's and ulcerative colitis, respectively. Eighty-four percent of ulcerative colitis patients and 91 percent of Crohn's disease patients reported an improvement in their quality of life, and overall, more than 90 percent considered their health status to be better than before surgery. One patient with ulcerative colitis developed carcinoma of the rectal stump 11.5 years after the colectomy and ileorectal anastomosis (cumulative probability of remaining free of cancer, 85.7 percent at 12 years; 95 percent confidence interval, 57.7-100 percent). CONCLUSIONS These results demonstrate that, in selected patients with a relatively spared rectum and without severe perineal disease, total colectomy and ileorectal anastomosis still remains a viable option to total proctocolectomy with extensive Crohn's colitis. In addition, ileorectal anastomosis, as a sphincter-saving procedure, continues to have a place in the surgical treatment of chronic ulcerative colitis for high-risk or older patients who are not good candidates for ileal pouch-anal anastomosis, when the latter procedure cannot be done because of technical reasons and in the presence of advanced carcinoma concomitant with colitis, when life expectancy is limited.
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Affiliation(s)
- R L Pastore
- Division of Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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48
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Abstract
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.
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Affiliation(s)
- V W Fazio
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio, USA
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Platell C, Mackay J, Collopy B, Fink R, Ryan P, Woods R. Crohn's disease: a colon and rectal department experience. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1995; 65:570-5. [PMID: 7661797 DOI: 10.1111/j.1445-2197.1995.tb01697.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This study reviewed a series of patients with Crohn's disease managed by surgeons of the Department of Colon and Rectal Surgery, St Vincent's Hospital, Melbourne, since 1978. There were 306 patients: 171 males and 135 females. The mean age at diagnosis was 33.4 years (ranger 11-93). The distribution of the disease was small bowel 32.3%, small bowel and colon 26.5%, colon 39.9%, and anal disease alone 1.6%. A total of 416 abdominal operations were performed on 204 patients. The commonest indications for surgery were failed medical therapy (21.9%), small bowel obstruction (15.9%), enteric fistula (10.1%), and intra-abdominal abscess (10.1%). The most frequently performed procedures were ileocolic resection with anastomosis (28.8%), small bowel resection (9.4%), and total colectomy and ileostomy (7.0%). Postoperative complications included anastomotic leaks in 4.0%, intra-abdominal abscess formation in 3.6%, and enterocutaneous fistulae developed in 6%. Three patients died during the review period. During follow up (mean 84.4), 30% of patients developed recurrence requiring further surgery at a mean of 72.7 months postoperatively. The most frequent site for a recurrence was the pre-anastomotic terminal ileum (61.7%). In conclusion, the majority of patients with Crohn's disease will require resectional surgery at some stage. This can be performed with a low mortality and morbidity, and a recurrence rate of around 5% per year.
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Affiliation(s)
- C Platell
- Department of Colon and Rectal Surgery, St Vincent's Hospital, Fitzroy, Victoria, Australia
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Chevalier JM, Jones DJ, Ratelle R, Frileux P, Tiret E, Parc R. Colectomy and ileorectal anastomosis in patients with Crohn's disease. Br J Surg 1994; 81:1379-81. [PMID: 7953424 DOI: 10.1002/bjs.1800810945] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- J M Chevalier
- Service de Chirurgie Digestive, Hôpital St Antoine, Paris, France
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