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Celentano V, Pellino G, Rottoli M, Poggioli G, Sica G, Giglio MC, Campanelli M, Coco C, Rizzo G, Sionne F, Colombo F, Sampietro G, Lamperti G, Foschi D, Ficari F, Vacca L, Cricchio M, Giudici F, Selvaggi L, Sciaudone G, Peltrini R, Manfreda A, Bucci L, Galleano R, Ghazouani O, Zorcolo L, Deidda S, Restivo A, Braini A, Di Candido F, Sacchi M, Carvello M, Martorana S, Bordignon G, Angriman I, Variola A, Barugola G, Di Ruscio M, Tanzanu M, Geccherle A, Tropeano FP, Luglio G, Sasia D, Migliore M, Giuffrida MC, Marrano E, Moretto G, Impellizzeri H, Gallo G, Vescio G, Sammarco G, Terrosu G, Calini G, Bondurri A, Maffioli A, Zaffaroni G, Resegotti A, Mistrangelo M, Allaix ME, Botti F, Prati M, Boni L, Perotti S, Mineccia M, Giuliani A, Romano L, Graziano GMP, Pugliese L, Pietrabissa A, Delaini GG, Spinelli A, Selvaggi F. Surgical treatment of colonic Crohn's disease: a national snapshot study. Langenbecks Arch Surg 2021; 406:1165-1172. [PMID: 33263140 PMCID: PMC8208904 DOI: 10.1007/s00423-020-02038-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/17/2020] [Indexed: 02/07/2023]
Abstract
AIM The different surgical options for patients with colonic Crohn's disease (CD) include segmental colectomy, subtotal colectomy or proctocolectomy with end ileostomy. We present a national, multicentre study, promoted by the Italian Society of Colorectal Surgery with the aim to collect benchmark data and national variations on multidisciplinary management and postoperative outcomes of patients undergoing surgery for colonic CD. METHODS All adult patients having elective surgery for colonic CD from June 2018 to May 2019 were eligible for participation in this retrospective study. The primary outcome measure was postoperative morbidity within 30 days of surgery. RESULTS One hundred twenty-two patients were included: 55 subtotal colectomy, 30 segmental colectomy, 25 proctectomy and 12 proctocolectomy. Eighty-six patients (70.4%) were discussed at the inflammatory bowel disease (IBD) multidisciplinary team meeting (MDT) prior to surgery. This ranged from 76.6% for segmental colectomy to 60% for subtotal colectomy, 66.6% for proctocolectomy and 48% for proctectomy. The proportion of patients counselled by a stoma nurse preoperatively was 50%. Laparoscopy was associated with reduced postoperative morbidity (p = 0.017) and shorter length of hospital stay (p < 0.001), whilst pre-operative anti-TNF was associated with Dindo-Clavien ≥ 3 complications (p = 0.023) and longer in-hospital stay (p = 0.007). The main procedure performed (segmental colectomy, subtotal colectomy, proctocolectomy or proctectomy) was not associated with postoperative morbidity (p = 0.626). CONCLUSIONS Surgery for colonic CD has a high rate of postoperative complications. Almost a third of the patients were not preoperatively discussed at the IBD MDT, whilst the use of minimally invasive surgery for surgical treatment of colonic CD ranges from 40 to 66%.
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Chen PC, Kono T, Maeda K, Fichera A. Surgical technique for intestinal Crohn's disease. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Risk of postoperative morbidity in patients having bowel resection for colonic Crohn's disease. Tech Coloproctol 2018; 22:947-953. [PMID: 30543038 DOI: 10.1007/s10151-018-1904-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 12/04/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of the present multicenter study was to analyze the incidence and risk factors associated with postoperative morbidity in patients who had colorectal resection for colonic Crohn's disease. METHODS Consecutive patients undergoing colorectal resection for colonic Crohn's disease at seven surgical units in 1992-2017 were included. Exclusion criteria were: proctectomy for perianal disease, surgery for cancer, previous colectomies, surgery before 1998. Abdominal colectomy and proctocolectomy were defined as extended resections; all other operations were classified as segmental resections. Postoperative intraabdominal septic complications (IASC) were: anastomotic leaks, peritonitis and abscess. RESULTS One hundred ninety-nine patients met the inclusion criteria: 116 patients had segmental resections and extended resections were performed in 83 patients. An anastomosis was constructed in 122 patients and an additional stoma was formed in 15 of those cases. Segmental resections were performed significantly more frequently in stricturing or penetrating disease (93% vs. 61%, p < 0.001) and were completed by an anastomosis more often than extended resections (78% vs. 37%, p < 0.001). The overall IASC rate was 17%. On multivariate analysis, formation of an anastomosis (Hazard ratio 2.9; 95% CI 1.1-7.7; p = 0.036) and preoperative hemoglobin level of < 10 g/dl (Hazard ratio 3.1; 95% CI 1.1-9.1; p = 0.034) were associated with an increase of postoperative IASC rate. Preoperative medication did not influence postoperative outcome. CONCLUSIONS Severe preoperative anemia is associated with an increased postoperative morbidity. Resections completed by an anastomosis pose an increased postoperative complication risk in patients with colonic Crohn's disease as compared to resections without an anastomosis.
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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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Surgical recurrence in Crohn's disease: a comparison between different types of bowel resections. Int J Colorectal Dis 2018; 33:473-477. [PMID: 29492657 DOI: 10.1007/s00384-018-2995-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE To compare recurrence frequency and location between different types of bowel resections in Crohn's disease patients. METHODS This was a retrospective study of consecutive patients undergoing bowel resection for Crohn's disease between 2006 and 2016. Type of primary operation was recorded and grouped as ileocolic resection, small bowel resection, segmental colon resection with colocolic anastomosis or colorectal anastomosis, colectomy with ileorectal anastomosis, or end stoma operation. Binary logistic regression was used to compare surgical recurrence frequency between groups. We also investigated how Crohn's disease location at reoperations was related to the primary bowel resection type. RESULTS Altogether, 218 patients with a median follow-up of 4.7 years were included in our study. Reoperation was performed in 42 (19.3%) patients. The risk of reoperation using the ileocolic resection group as reference was the following: small bowel resection (odds ratio (OR) 2.95, 95% confidence interval (CI) 1.01-8.66; P = 0.049), segmental colon resection with colocolic or colorectal anastomosis (OR 6.20, 95% CI 2.04-18.87; P = 0.001), colectomy with ileorectal anastomosis (OR 26.57, 95% CI 2.59-273.01; P = 0.006), and end stoma operation (OR 4.62, 95% CI 1.90-11.26; P = 0.001). In case of surgical recurrence, the reoperation type and location correlated with the primary bowel resection type. CONCLUSIONS Reoperation frequency in Crohn's disease is lower after ileocolic resection than after other types of bowel resections. Surgical recurrence in Crohn's disease tends to maintain the disease location of the primary operation. One third of Crohn's patients undergoing an end stoma operation will still need new bowel resections due to recurrence.
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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
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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Parray FQ, Wani ML, Bijli AH, Thakur N, Irshad I, Nayeem-ul-Hassan. Crohn's disease: a surgeon's perspective. Saudi J Gastroenterol 2011; 17:6-15. [PMID: 21196646 PMCID: PMC3099084 DOI: 10.4103/1319-3767.74430] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Crohn's disease (CD) is known for wide anatomic distribution, different presentations, life-threatening complications, and multiple modalities of management. Its multiple implications are still unaddressed. Since all the patients do not show a good response to medical modalities of treatment, a significant percentage of these patients are referred to the surgeon for the palliation of complications or for the ultimate curative treatment. Since most surgeons come across such patients only rarely, it is sometimes difficult for them to choose the appropriate procedure at the time of need. Moreover, the various surgical modalities available for the different presentations and complications of the disease have not been adequately discussed. The aim of this review is to offer insight and a detailed account of the management of CD from a surgical perspective. This review offers an overview of the various surgical options available, their utility in context, and an approach to various scenarios of complicated CD.
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Affiliation(s)
- Fazl Q. Parray
- Department of General Surgery and Allied Specialities, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, India
| | - Mohd Lateef Wani
- Department of General Surgery and Allied Specialities, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, India,Address for correspondence: Dr. Mohd Lateef Wani, Senior Resident (General Surgery), F-12, B Block, Married Doctors Hostel, Skims Soura Srinager, Srinager, India. E-mail:
| | - Akram H. Bijli
- Department of General Surgery and Allied Specialities, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, India
| | - Natasha Thakur
- Department of General Surgery and Allied Specialities, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, India
| | - Ifat Irshad
- Department of General Surgery and Allied Specialities, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, India
| | - Nayeem-ul-Hassan
- Department of General Surgery and Allied Specialities, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, India
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Abstract
Restoration of the continuity of the intestinal tract is one of the key concepts for maintaining the quality of life in patients with Crohn's disease. Restorative procedures have an important role in the scope of operative modalities for these patients. The authors review operative options aimed at fulfilling these goals including restorative partial small bowel resection; segmental, subtotal, and total colectomies; and ileal pouch anal anastomosis in patients with Crohn's disease.
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Affiliation(s)
- Benjamin Person
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA.
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Maykel JA, Hagerman G, Mellgren AF, Li SY, Alavi K, Baxter NN, Madoff RD. Crohn's colitis: the incidence of dysplasia and adenocarcinoma in surgical patients. Dis Colon Rectum 2006; 49:950-7. [PMID: 16729218 DOI: 10.1007/s10350-006-0555-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE Data supporting an increased risk of colorectal cancer in patients with Crohn's colitis are inconsistent. Despite this, clinical recommendations regarding colonoscopic screening and surveillance for patients with Crohn's colitis are extrapolated from chronic ulcerative colitis protocols. The primary aim of our study was to determine the incidence of dysplasia and carcinoma in pathology specimens of patients undergoing segmental or total colectomy for Crohn's disease of the large bowel. In addition, we sought to identify risk factors associated with the development of dysplasia and carcinoma. METHODS We performed a retrospective review of all patients operated on at our institution for Crohn's colitis between January 1992 and May 2004. Data were retrieved from patient charts, operative notes, and pathology reports. Logistic regression was used to model the probability of having dysplasia or adenocarcinoma. RESULTS Two hundred twenty-two patients (138 females) who underwent surgical resection for the treatment of Crohn's colitis were included in the study. Mean age at surgery was 41 (range, 15-82) years and the mean duration of disease was 10 (range, 0-53) years. There were five cases of dysplasia (2.3 percent) and six cases of adenocarcinoma (2.7 percent). Three patients with dysplasia and one with adenocarcinoma were diagnosed on preoperative colonoscopy; while the other cases were discovered incidentally on pathologic examination of resected specimens. Factors associated with the presence of dysplasia or adenocarcinoma included older age at diagnosis (38.2 vs. 30.3 years, P = 0.02), longer disease duration (16.0 vs. 10.1 years, P = 0.05), and disease extent (90 percent extensive vs. 59 percent limited, P = 0.05). CONCLUSIONS Patients with severe Crohn's colitis requiring surgery are at significant risk for developing dysplasia and adenocarcinoma, particularly when diagnosed at an older age, after longer disease duration, and with more extensive colon involvement.
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Affiliation(s)
- Justin A Maykel
- Department of Surgery, Section of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
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12
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Tekkis PP, Purkayastha S, Lanitis S, Athanasiou T, Heriot AG, Orchard TR, Nicholls RJ, Darzi AW. A comparison of segmental vs subtotal/total colectomy for colonic Crohn's disease: a meta-analysis. Colorectal Dis 2006; 8:82-90. [PMID: 16412066 DOI: 10.1111/j.1463-1318.2005.00903.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Using meta-analytical techniques the present study evaluated differences in short-term and long-term outcomes of adult patients with colonic Crohn's disease who underwent either colectomy with ileorectal anastomosis (IRA) or segmental colectomy (SC). METHODS Comparative studies published between 1988 and 2002, of subtotal/total colectomy and ileorectal anastomosis vs segmental colectomy, were used. The study end points included were surgical and overall recurrence, time to recurrence, postoperative morbidity and incidence of permanent stoma. Random and fixed-effect meta-analytical models were used to evaluate the study outcomes. Sensitivity analysis, funnel plot and meta-regressive techniques were carried out to explain the heterogeneity and selection bias between the studies. RESULTS Six studies, consisting of a total of 488 patients (223 IRA and 265 SC) were included. Analysis of the data suggested that there was no significant difference between IRA and SC in recurrence of Crohn's disease. Time to recurrence was longer in the IRA group by 4.4 years (95% CI: 3.1-5.8), P < 0.001. There was no difference between the incidence of postoperative complications (OR = 1.4., 95% CI 0.16-12.74) or the need for a permanent stoma between the two groups (OR = 2.75, 95% CI 0.78-9.71). Patients with two or more colonic segments involved were associated with lower re-operation rate in the IRA group, a difference which did not reach statistical significance (P = 0.177). CONCLUSIONS Both procedures were equally effective as treatment options for colonic Crohn's disease however, patients in the SC group exhibited recurrence earlier than those in the IRA group. The choice of operation is dependent on the extent of colonic disease, with a trend towards better outcomes with IRA for two or more colonic segments involved. Since no prospective randomised study has been undertaken, a clear view about which approach is more suitable for localised colonic Crohn's disease cannot be obtained.
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Affiliation(s)
- P P Tekkis
- Imperial College London, Department of Surgical Oncology and Technology, UK.
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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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14
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Abstract
An overlap of inflammatory bowel disease and diverticular disease has long been recognized. Crohn's disease and diverticulitis share clinical and radiologic features but usually differ in histopathologic findings. There is a suggestion, however, that even the characteristic pathology of Crohn's disease can be a secondary reaction to diverticulitis. It is possible, moreover, that the presence of Crohn's disease in association with diverticulosis predisposes to the development of diverticulitis. Finally, an apparently distinct form of segmental colitis associated with sigmoid diverticula has been described further contributing to the overlap of inflammatory bowel disease and diverticular disease.
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Affiliation(s)
- Mark A Peppercorn
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Rabb 420, Boston, MA 02215, USA.
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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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16
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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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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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18
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Prabhakar LP, Laramee C, Nelson H, Dozois RR. Avoiding a stoma: role for segmental or abdominal colectomy in Crohn's colitis. Dis Colon Rectum 1997; 40:71-8. [PMID: 9102265 DOI: 10.1007/bf02055685] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
UNLABELLED Total proctocolectomy and ileostomy for Crohn's colitis offers a low recurrence rate but commits patients to a permanent ileostomy. In contrast, segmental resection may predispose patients to recurrence and further surgery but may delay or avoid a stoma in select individuals. AIM This study was undertaken to determine the risk of recurrence and the need for permanent stoma in patients treated with segmental or abdominal colectomy for Crohn's colitis. METHODS Between 1976 and 1985, 699 patients underwent surgery for Crohn's colitis at the Mayo Clinic. Patients who had a total proctocolectomy and end ileostomy or primary ileal or anorectal disease were excluded from further study. Fifty-three patients had a colon resection without a permanent stoma, and 49 were alive and available for follow-up. During a mean follow-up of 14 years, completed questionnaires provided current details on subsequent medical and surgical therapies and/or stomas that were required. In these 49 patients, Crohn's of the colon involved the right, left, and both sides of the colon in 12, 31, and 6 patients, respectively, and involved less than one-third, one to two-thirds, and greater than two-thirds of the colon in 23, 25, and 1 patients, respectively. RESULTS Twenty-two of forty-nine patients (45 percent) required no further therapy. In 27 patients (55 percent), further treatment was required, including 11 (22 percent) patients who were managed medically (only 4 >1 year) and 16 (33 percent) patients who were managed surgically. Three recurrences developed in the small bowel; the remaining 24 developed in the colon. For the 16 patients with recurrence requiring surgery, mean time to recurrence was 51 +/- 14 months; in all cases, recurrent disease involved the colon, with four anastomotic recurrences. At first recurrence, ten patients underwent another limited colon resection, and six patients underwent completion proctectomy with permanent ileostomy. Five patients required a third procedure, only one of which resulted in a permanent ileostomy. Therefore, 42 patients (86 percent) remained stoma-free, and 7 (14 percent) ultimately required permanent ileostomy, with a mean stoma-free interval of 23 +/- 4 months. CONCLUSION Colon resection without proctectomy in select patients with limited colonic Crohn's disease can delay or avoid the necessity of a permanent stoma.
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Affiliation(s)
- L P Prabhakar
- Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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19
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Abstract
The varied presentations and complexities of Crohn's disease involving the colon, rectum, and anus mandate decisions that can challenge even the most experienced surgeon. Symptomatic large-bowel disease, with its number of operative indications, is often amenable to resection that maintains intestinal continuity with acceptable rates of recurrence. Disease of the anus, occurring with or without proximal disease, typically is treated in a conservative manner, although occasional definitive treatment may yield improved results. As Crohn's disease is recognized as incurable, the treatment options discussed focus on the amelioration of symptoms while optimizing function without risking excessive morbidity.
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Affiliation(s)
- S A Strong
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio
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20
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Harling H, Hegnhøj J, Rasmussen TN, Jarnum S. Fate of the rectum after colectomy and ileostomy for Crohn's colitis. Dis Colon Rectum 1991; 34:931-5. [PMID: 1914729 DOI: 10.1007/bf02049711] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Eighty-four patients had colectomy with ileostomy and oversewing of the rectum for Crohn's colitis. Seventy-two patients were operated on because of intractable disease, colitis in combination with rectal fistulas, and toxic megacolon. The operative mortality was 6 percent, and neither emergency surgery nor treatment with steroids correlated with operative morbidity. After a median 7.7 years of follow-up, 25 ileorectal anastomoses had been undertaken, 16 of which were successful. Twenty-nine protectomies were performed; the resulting 10-year cumulative risk of proctectomy was 50 percent. While the risk of proctectomy was significantly less among patients with a normal rectum at colectomy compared with patients with proctitis, the initial macroscopic degree of proctitis did not correlate with the risk of subsequent proctectomy. The 5-year cumulative ileal resection rate in 29 patients with a rectum in situ but out of circuit was 29 percent. The possibility of a future ileorectal anastomosis should still be considered in patients with proctocolitis.
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Affiliation(s)
- H Harling
- Department of Surgical Gastroenterology C, Rigshospitalet, University of Copenhagen, Denmark
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McCue J, Coppen MJ, Rasbridge SA, Lock MR. Coexistent Crohn's disease and sigmoid diverticulosis. Postgrad Med J 1989; 65:636-9. [PMID: 2608592 PMCID: PMC2429186 DOI: 10.1136/pgmj.65.767.636] [Citation(s) in RCA: 59] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This study reports six patients with a diagnosis of diverticular disease with associated localized Crohn's colitis who were all treated by segmental resection. Two patients died in the post-operative period from disease unrelated to their colonic pathology. The remaining four patients remain well, show no signs of recurrent disease and have required no further surgery. The behaviour and significance of the two conditions occurring in the same patient is discussed.
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Affiliation(s)
- J McCue
- Department of Surgery, Whittington Hospital, London, UK
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22
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Abstract
Total parenteral nutrition now permits long-term survival in patients after massive intestinal resection. Surgical therapy for the short-bowel syndrome is still largely experimental and cannot be recommended routinely. Thus, prevention of intestinal resection and conservation of intestinal length, when resection is necessary, should be emphasized. Strategies are presented that can be employed to preserve intestinal length when surgery is required in patients with a shortened bowel. These include strictureplasty, minimal resection, serosal patching, and intestinal tapering. In suitable candidates strictureplasty can relieve obstruction from strictures while avoiding resection. Minimal resection of involved intestine can be performed safely in selected patients with radiation injury or Crohn's disease. Serosal patching is an alternative to resection for the treatment of perforation or strictures of the intestine. Intestinal tapering can improve the function of dilated intestinal segments and eliminate the need for resection in intestinal atresia. The judicious use of these procedures can preserve intestinal length and obviate the need for long-term parenteral nutrition in patients after massive intestinal resection.
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