Gastroduodenal fistulas in Crohn's disease: clinical features and management

Optimal surgical management of duodenal fistula in Crohn's disease: a Korean multicenter cohort study

PURPOSE

Duodenal fistula in Crohn's disease (CDF) is a rare condition with an unclear optimal surgical management approach. We reviewed a Korean multicenter cohort of CDF surgery cases and assessed their perioperative outcomes to evaluate the effectiveness of the surgical interventions.

METHODS

The medical records of patients who underwent CD surgery between January 2006 and December 2021 from three tertiary medical centers were retrospectively reviewed. Only CDF cases were included in this study. The demographic and preoperative characteristics, perioperative details, and postoperative outcomes were analyzed.

RESULTS

Among the initial population of 2149 patients who underwent surgery for CD, 23 cases (1.1%) had a CDF operation. Fourteen of these patients (60.9%) had a history of previous abdominal surgery, and 7 had duodenal fistula at the previous anastomosis site. All duodenal fistulas were excised and primarily repaired via a resection of the originating adjacent bowel. Additional procedures such as gastrojejunostomy, pyloric exclusion, or T-tube insertion were performed in 8 patients (34.8%). Eleven patients (47.8%) experienced postoperative complications including for anastomosis leakages. Fistula recurrence was noted in 3 patients (13%) of which one patient required a re-operation. Biologics administration was associated with fewer adverse events by multivariable analysis (P = 0.026, odds ratio = 0.081).

CONCLUSION

Optimal perioperative conditioning of patients receiving a primary repair of a fistula and resection of the original diseased bowel can successfully cure CDF. Along with primary repair of the duodenum, other complementary additional procedures should be considered for better postoperative outcomes.

Prevalence, diagnosis, and surgical management of complex ileocolic-duodenal fistulas in Crohn's disease

BACKGROUND

The aim of the present study was to review the prevalence and surgical management of patients with Crohn's disease (CD) complicated by ileocolic-duodenal fistulas (ICDF).

METHODS

We performed a retrospective chart review of CD patients who underwent surgical takedown and repair of ICDF during January 2011-December 2021 at two inflammatory bowel disease referral centers.

RESULTS

We identified 17 patients with ICDF (1.3%) out of 1283 CD patients who underwent abdominal surgery. Median age was 42 (20-71) years, 13 patients were male (76%) and median body mass index was 22.7 (18.4-30.3) kg/m². Four patients (24%) were diagnosed preoperatively and only 2 (12%) were operated on for ICDF-related symptoms. The most common procedure was ileocolic resection (13 patients, 76%) including 4 repeat ileocolic resections (24%). The duodenal defect was primarily repaired in all patients with no re-fistulization or duodenal stenosis, regardless of the repair technique. A laparoscopic approach was attempted in the majority of patients (14 patients, 82%); however, only 5 (30%) were laparoscopically completed. The overall postoperative complication rate was 65% including major complications in 3 patients (18%) and 2 patients (12%) who required surgical re-intervention for abdominal wall dehiscence and postoperative bleeding. Preoperative nutritional optimization was performed in 9 patients (53%) due to malnutrition. These patients had significantly less intra-operative blood loss (485 vs 183 ml, p = 0.05), and a significantly reduced length of stay (18 vs 8 days, p = 0.05).

CONCLUSION

ICDF is a rare manifestation of CD which may go unrecognized despite the implementation of a comprehensive preoperative evaluation. Although laparoscopic management of ICDF may be technically feasible, it is associated with a high conversion rate. Preoperative nutritional optimization may be beneficial in improving surgical outcomes in this select group of patients.

Upper Gastrointestinal Manifestations of Inflammatory Bowel Disease

Although the features of lower gastrointestinal tract inflammation associated with ulcerative colitis and Crohn disease are generally familiar to pathologists, there is less awareness of and familiarity with the manifestations of inflammatory bowel disease in the esophagus, stomach, and duodenum. Nonetheless, their diagnosis has therapeutic and possibly prognostic implications, potentially foretelling severe complications. The recognition that ulcerative colitis can affect gastrointestinal organs proximal to the large intestine and terminal ileum represents a revision of concepts ingrained among generations of physicians. This article reviews the pathologic features and clinical significance of esophagitis, gastritis, and duodenitis associated with inflammatory bowel disease.

Histologically confirmed upper gastrointestinal Crohn's disease: is it rare or are we just not searching hard enough?

Background/Aims

Crohn’s disease (CD) may involve the upper parts of the gastrointestinal (GI) tract including the esophagus, stomach, and duodenum. Clinical features of upper GI CD (UGICD) are not well characterized in the Gulf region. We therefore aimed to assess the prevalence and clinical characteristics of patients diagnosed with UGICD.

Methods

We performed a retrospective analysis of all patients diagnosed with CD who underwent upper GI endoscopy between 2012 and 2017 at King Abdulaziz University Hospital, irrespective of age. Patients who had endoscopy of the upper GI tract at baseline and had histologically confirmed UGICD were included. Data on patients’ demographics, clinical characteristics, extraintestinal manifestations and complications were reviewed.

Results

We identified 78 CD patients who underwent upper GI endoscopy from our medical records. The mean age was 17.2±8.7 years and 55.1% were males. Of the total, 19 out of 78 patients (24.4%) had histologically confirmed UGICD (3 esophageal, 16 gastric, and 9 duodenal), of which 52.6% were symptomatic. Disease distribution was ileal in 57.8%, colonic in 21.1% and ileo-colonic in 21.1%. A non-stricturing and non-penetrating phenotype was reported in 89.4%, stricturing in 5.3%, and penetrating in 5.3%. Perianal disease was found in 10.5%. UGICD was complicated by stricture formation in 2 patients (esophageal and gastric).

Conclusions

The prevalence of UGICD is considered high among CD Saudi patients who undergo upper GI endoscopy at baseline, and is asymptomatic in 47.4% of patients. This reported prevalence is not dissimilar from reports originating from Western countries.

Efficacy of Endoscopic Dilation of Gastroduodenal Crohn's Disease Strictures: A Systematic Review and Meta-Analysis of Individual Patient Data

BACKGROUND & AIMS

Little is known about the effects of endoscopic balloon dilation (EBD) for strictures of the upper gastrointestinal (UGI) tract in patients with Crohn's disease (CD). We performed a pooled analysis of the efficacy and safety of EBD for UGI CD-associated strictures.

METHODS

We searched Embase, Medline, and the Cochrane library, as well as bibliographies of relevant articles, for cohort studies of adults with CD and strictures of the stomach or duodenum (up to the ligament of Treitz) who underwent EBD through December 2016. We obtained data from 7 international referral centers on 94 patients who underwent 141 EBDs. We performed a patient-level meta-analysis of data from published and unpublished cohort studies to determine mechanical and clinical success. We performed a time-to-event analysis to assess symptom recurrence and need for redilation or surgery. The patients analyzed had strictures of the duodenum (n = 107), stomach (n = 30), or spanning both (n = 4).

RESULTS

The rate of technical success for EBD was 100%, with 87% short-term clinical efficacy; major complications arose from 2.9% of all procedures. During a median follow-up period of 23.1 months, 70.5% of patients had a recurrence of symptoms, 59.6% required redilation, and 30.8% required surgical intervention. Patients whose disease was located in the small bowel had a higher risk for symptom recurrence (hazard ratio [HR], 2.1; P = .003). Asian race (HR, 2.8; P < .001) and location of disease in the small bowel (HR, 1.9; P = .004) increased the need for redilation. Prestenotic dilation was a risk factor for needing surgery earlier (HR, 1.9; P = .001).

CONCLUSIONS

In a meta-analysis, we found EBD for CD-associated strictures of the UGI to be an effective alternative to surgery, with a high rate of short-term technical and clinical success, moderate long-term efficacy, and an acceptable rate of complications.

Reoperative Surgery in Complex Crohn's Disease

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.

Surgical Management of Complex Enteric Fistulas in Crohn's Disease

Crohn's disease is a chronic, inflammatory bowel condition that can affect the entire digestive tract and in many cases lead to enteric fistula formation. The management of enteric fistulas can be challenging and often requires a multidisciplinary approach.

Crohn's Disease of the Esophagus, Duodenum, and Stomach

Upper gastrointestinal Crohn's is an under-reported, under-recognized phenotype of Crohn's disease. Routine screening in the pediatric population has shown a higher prevalence compared with adults; however, most adult patients remain asymptomatic with respect to upper gastrointestinal Crohn's disease. For the patients who are symptomatic, medical treatment is the first line of management, except for cases of obstruction, perforation, or bleeding. Though most patients respond to medical therapy, mainly steroids, with the addition of immunomodulators and more recently biologics agents, surgical intervention is usually required only for obstructing gastroduodenal disease secondary to strictures. Strictureplasty and bypass are safe operations with comparable morbidity, although bypass has higher rates of dumping syndrome and marginal ulceration in the long term. Rare cases of gastroduodenal fistulous disease from active distal disease may involve the stomach or duodenum, and esophageal Crohn's disease can fistulize to surrounding structures in the mediastinum which may require the highly morbid esophagectomy.

Outcome of Surgery for Coloduodenal Fistula in Crohn's Disease

BACKGROUND

This study was conducted to report the short- and long-term outcomes of surgery for coloduodenal fistula in Crohn's disease and explore the effect of preoperative optimization on surgical outcome.

METHODS

This is a retrospective review of 34 patients with coloduodenal fistula complicating Crohn's disease between Jan 2008 and May 2015. Demographic information, preoperative management, and intraoperative and postoperative outcome data were collected.

RESULTS

Primary duodenal repair was carried out in 33 patients (13 with duodenal defect >3 cm), and bypass surgery was performed in one patient with duodenal stenosis. Patients undergoing preoperative optimization (n = 25) had decreased postoperative major (24.0 vs. 87.5 %, P = 0.005) and intra-abdominal septic (20.0 vs. 75.0 %, P = 0.008) complications compared to patients with emergent/semi-emergent surgery (n = 8). No duodenal stenosis occurred on a median follow-up of 22.5 months. Patients with duodenum-ileocolic anastomosis fistula had longer postoperative stay (14.0 vs. 10.0 days, P = 0.032) and increased possibility of refistulization of the duodenum on follow-up (30.0 vs. 0 %, P = 0.031) compared with those with spontaneous duodenum-colonic fistula.

CONCLUSION

Primary duodenal repair can be safely performed in coloduodenal fistula in Crohn's disease provided there was no duodenal stenosis, even for large duodenal defects. Preoperative optimization is associated with reduced postoperative complications. Patients with duodenum-ileocolic anastomosis fistula are more likely to have duodenum fistula recurrence compared to those with spontaneous duodenum-colonic fistula.

Crohn's Disease of the Foregut

Crohn's disease of the foregut is more common than previously recognized, with up to 40% of patients with Crohn's disease in the distal intestine also having evidence of foregut disease. Esophageal disease is best managed medically with proton pump inhibition, steroids, thiopurines, methotrexate, and anti-tumor necrosis factor-α biologic medications. Esophageal strictures are dealt with using endoscopic dilation. Surgery is generally reserved of resistant strictures or esophageal fistulas. Patients with gastroduodenal disease more commonly come to surgery. The most commonly performed operations for gastroduodenal Crohn's disease are intestinal bypass or strictureplasty. The concomitant use of vagotomy remains controversial.

Current status in the multidisciplinary management of duodenal fistula

INTRODUCTION

Paradigms in the management of duodenal fistula have evolved over the last half a century. Despite advances, morbidity and mortality still remain high. This paper provides a comprehensive, up to date, systematic review in the management of duodenal fistula, classifying the various strategies in the management of duodenal fistula

MATERIALS AND METHODS

A review was performed on Medline, Embase and Cochrane library databases using the Cochrane systematic reviews methodology. A final population of 42 studies reported on 349 patients, with a median (range) number of patients per study of two (1-68). The manuscripts were broadly divided in to "non-interventional" and "interventional". The interventional group was subdivided in to "minimally invasive" and the "open surgical approach".

RESULTS

A total of 147 patients were treated conservatively (non-interventional group), with a median duration of 28 days (range 13-42 days) with 13 (9%) deaths recorded in this group. No deaths were reported in the 8 reports on minimally invasive approach.166 patients had open surgical approach with a mortality rate of 30% (50 patients).

DISCUSSION AND CONCLUSION

In the absence of randomised controlled trials, no one interventional modality can be considered superior. Initial multidisciplinary conservative approach with sepsis control and nutritional augmentation should be for 6 weeks. It would seem reasonable, in those fistulae that fail to close spontaneously, to attempt a low risk "minimally invasive" intervention where necessary expertise is available. More risky open surgical approaches should clearly be reserved for those that fail and are best performed in specialist centres.

Simultaneous occurrence of hyperthyroidism and fistulizing Crohn's disease complicated with intra-abdominal fistulas and abscess: a case report and review of the literature

Introduction

Fistula formation in patients with Crohn’s disease is a common complication during the course of the disease. Perianal and enteroenteric are the most common forms of fistulas, whereas the involvement of the upper gastrointestinal tract with gastrocolic and duodenocolic fistulas represents an extremely unusual condition. Moreover, hyperthyroidism in association with Crohn’s disease has been rarely described.

Case presentation

We present here a rare case of a 25-year-old male with simultaneous onset of hyperthyroidism and fistulizing Crohn’s disease. Crohn’s disease was complicated with intra-abdominal fistulas involving the upper gastrointestinal tract (duodenocolic, gastrocolic) and an intra-peritoneal abscess formation in the lesser sac. We describe the clinical presentation and therapeutic management of the patient including both medical treatment and surgical intervention. Despite intense medical treatment with total parenteral nutrition, antibiotics, aminosalicylates and corticosteroids the clinical course of the disease was suboptimal. Finally, the patient underwent laparotomy and right hemi-colectomy with ileo-transverse anastomosis performed, with simultaneous drainage of the abdominal abscess and primary closure of the upper gastrointestinal tract openings (gastric, duodenal and jejunal) at one stage operation. Although the surgical approach definitively cured the perforating complications of the disease (fistulas and abscess), the luminal disease in the colon remnant was still active and steroid-refractory. The subsequent successful treatment with infliximab, azathioprine and mesalazine resulted in the induction and maintenance of the disease remission. Thyrotoxicosis was successfully treated with methimazole and the hyperthyroidism has definitely subsided.

Conclusion

The management of intra-abdominal fistulas in Crohn’s disease is a complex issue, requiring a multi-disciplinary approach and ‘tailoring’ of the treatment to the individual patient’s needs. Probably, a sensible approach involves early surgical intervention with prior optimization of the patient’s general condition when feasible. Common autoimmune mechanisms are probably involved in thyroid dysfunction associated with Crohn’s disease. Moreover, diagnosis and treatment of coexisting thyroid disorder in patients with Crohn’s disease has a favorable impact in disease prognosis.

Biliogastric diversion for the management of high-output duodenal fistula: report of two cases and literature review

High-output duodenal fistula occurs as a result of a duodenal wall defect caused by gastroduodenal surgery, endoscopic sphincterotomy, duodenal injury, and tumors with high morbidity and mortality rate. A new technique for its management is reported along with literature review. This procedure consists of transection of the duodenum 2 cm distally to the pylorus, transection of the common bile duct, and end duodenostomy with or without suturing the duodenal wall defect. The continuity of the alimentary tract is reinstated by an end-to-end duodenojejunostomy, end-to-side choledochojejunostomy, and end-to-side Roux-en-Y jejunojejunostomy, obtaining biliogastric diversion from the duodenum and closure of the fistula. This technique was performed in two patients with excellent results.

Surgical management and outcomes of patients with duodenal Crohn's disease

BACKGROUND

Duodenal Crohn's disease (DCD) has been reported to occur in 0.5% to 4% of patients with Crohn's disease. When patients fail to respond to conservative therapy or severe narrowing of the duodenum develops, operation is required. The recent literature is limited in description of surgical treatment of such patients. We reviewed our experience with surgical management and outcomes in patients with DCD, including outcomes of laparoscopic bypass procedures.

STUDY DESIGN

A retrospective review was undertaken of all patients who underwent surgical intervention for DCD between 1995 and 2006. Data collected included demographics, clinical presentation, operative and hospital course, and postoperative followup.

RESULTS

Thirty patients had surgical intervention for DCD during the selected period. Four patients had duodenoenteric fistulas, resulting from complications of their disease in the distal gastrointestinal tract. Operations done for intrinsic DCD were: open bypass (n = 11), laparoscopic bypass (n = 13), and stricturoplasty (n = 2). Only one vagotomy was done. Mean followup was 58 months (range 6 to 144 months). Patients resumed oral diet 3.0 days after laparoscopic bypass, with mean discharge of 6.9 days, as compared with 4.4 days and 12.2 days after open bypass, respectively. In the early postoperative period (0 to 30 days), six major complications (n=5, 19%): persistent obstruction, anastomotic leak, small bowel obstruction, anastomotic bleeding (two patients), and respiratory failure, developed in four patients in the open (36%) and one patient in the laparoscopic (8%) bypass group. There were two more complications during longterm followup, for an overall major morbidity rate of 27%. Two patients experienced recurrence requiring revision (one in the open group and one in the laparoscopic group). Gastroduodenal ulcers requiring operation did not develop in any of the patients.

CONCLUSIONS

Surgery is a viable and safe option for patients with intractable duodenal Crohn's disease. The laparoscopic approach during a bypass procedure, as opposed to an open bypass, may result in faster recovery, less morbidity, and comparable recurrence rate. There is no role for vagotomy in bypass procedures.

Upper gastrointestinal tract endoscopy in inflammatory bowel disease

Upper gastrointestinal endoscopy is used to evaluate upper gastrointestinal symptoms in patients with inflammatory bowel disease. This article discusses the procedure, which may allow for the diagnosis of Crohn's disease of the esophagus, stomach, and/or duodenum. Biopsies of normal gastric mucosa in patients with indeterminate colitis may be helpful in making a diagnosis of Crohn's colitis. Upper gastrointestinal endoscopy may allow for therapeutic intervention in terms of bleeding and stricturing disease.

Management of internal fistulas in Crohn's disease

Internal fistulas occur in 5-10% of patients with Crohn's disease. The clinical presentation of each of the three main types of internal fistulas--enteroenteric, enterovaginal, and enterovesical fistulas--is important in determining the best management. Asymptomatic fistulas usually require no treatment, but fistulas that cause severe or persistent symptoms necessitate intervention. Previously regarded as a surgical condition requiring resection, some internal fistulas are amenable to a more conservative approach involving medical therapy, surgical repair, or both. So far, there have not been any prospective studies designed specifically to assess the efficacy of a medical treatment of internal fistulas, and information about treatment results is gleaned from trials in which patients with internal fistulas have been included and from retrospective reports. Drugs that have been reported to close internal fistulas partially or completely include azathioprine, 6-mercaptopurine, mycophenolate mofetil, cyclosporine A, tacrolimus, and infliximab. Reparative surgical techniques include transrectal and transvaginal mucosal advancement flaps, cutaneous advancement flap, and anal stricturectomy in combination with a rectal mucosal advancement sleeve. Prospective trials of medical therapy and combination medical and surgical therapy for internal fistulas are needed to provide evidence to support the use of these new therapeutic approaches.

Proximal Crohn's disease: review of the clinicopathologic features and therapy

Crohn's disease in the proximal region of the digestive tract is uncommon. Better diagnostically procedures and more careful histologic examination has led to a higher detection of proximal Crohn's disease. The diagnosis is based on symptoms, endoscopy with serial sections, or double contrast radiography. The most common histologic finding for this diagnosis are granulomas in the mucosa in Helicobacter pylori-negative patients, but the granulomas are not always frequently detected. Endoscopic lesions in the proximal regions look like the lesions that could be found in the distal regions. Notching in the duodenal folds could be a strong indication for Crohn's desease. Radiological lesions are not always characteristic, but should be used in combination with endoscopy. Stenosis is an important complication, but fistula formation and pseudodiverticular formation is possible. There is no uniform medical therapy, but the regular anti-inflammatory management for Crohn's disease is most often used. Sometimes surgery is needed.

Crohn's disease of the foregut

Historically, Crohn's disease of the esophagus, stomach, and duodenum has been reported only rarely. With more frequent use of upper endoscopy, however, upper gastrointestinal involvement has been found to be more common than previously suspected. The surgeon with an interest in Crohn's disease needs to be familiar with all areas that are potentially affected in this perplexing and sometimes devastating disease. This article examines the literature on foregut Crohn's and discusses the incidence, clinical manifestations, diagnosis, medical management, surgical indications, and operative techniques.

An audit of gastroduodenal Crohn disease: clinicopathologic features and management

BACKGROUND

This study was undertaken to assess the clinicopathologic features and management of gastroduodenal Crohn disease.

METHODS

The medical records of 54 patients with gastroduodenal Crohn disease treated between 1958 and 1997 were reviewed.

RESULTS

Gastroduodenal Crohn disease occurred in association with disease elsewhere in 52 patients (96%). The commonest pathology was stricture (n = 41), followed by ulceration (n = 4) and duodenocutaneous fistula (n = 2). Medical treatment was initially attempted in 31 patients, of whom 12 required no surgical treatment for gastroduodenal disease. Nineteen patients required surgery for gastroduodenal obstruction or fistula despite medical treatment. Overall, 33 patients (61%) required surgery; the indication was obstruction in 30, duodenocutaneous fistula in 2, and bleeding in 1. There was one postoperative death because of persistent bleeding and intraabdominal sepsis after oversewing of a bleeding ulcer. In obstructive disease 16 patients were treated by bypass surgery, 10 by strictureplasty, and 4 by gastrectomy. After surgery for obstructive disease anastomotic leak developed in three patients, and persistent gastric outlet obstruction was seen in six patients. In the long term 11 patients required reoperation for anastomotic obstruction (n = 9) or stomal ulceration (n = 2). For duodenocutaneous fistula one patient underwent simple closure of fistula, and the other patient duodenojejunostomy. Both of these patients developed an intra-abdominal abscess without evidence of leak. There has been no fistula recurrence.

CONCLUSIONS

Gastroduodenal Crohn disease is a complex and difficult problem that is associated with serious complications and need for reoperation.