The surgery of Crohn's disease

Fistulation as a complication of intra-abdominal soft-tissue sarcomas; a case series

Soft-tissue sarcomas are rare, accounting for only one percent of all cancers. They can occur in retroperitoneal and intraperitoneal sites, including gastrointestinal stromal tumours (GIST), and have the potential to cause complications secondary to interaction with other abdominal viscera. Fistulation, or an abnormal communication between two epithelium-lined surfaces that do not usually connect, is a rare example of such a complication. We present a series of cases of fistulation due to the presence of an intra-abdominal soft-tissue sarcoma and contrast three different approaches to management. We discuss the radiological features and other modalities of imaging which may be useful in diagnosing this rare complication.

Ileorectal fistula due to a rectal cancer-A case report

A 51-year-old man was seen at our hospital because of diarrhea. Barium enema and colonoscopy revealed a cancer in the lower rectum and fistula formation from the site to ileum. Resection of the rectal cancer and ileorectal fistula was performed. Histologically, the resected lesion was mucinous adenocarcinoma with contiguous invasion from the rectum to the ileum. The patient is alive with no sign of recurrence 120 months after operation. Fistula formation between the colon and other gastrointestinal tract organs is very rare, especially for rectal cancer. Fistula-forming colorectal cancers are rarely found to have metastatic lesions in the liver, peritoneum and lymph nodes despite their invasive behavior; accordingly, curative resection involving partial resection of the intestine with fistula is expected.

Differentiating enterocutaneous fistulae from suture abscesses complicating Crohn's disease using oral administration of indocyanine green

BACKGROUND AND AIM

Clinicians encounter difficulties distinguishing enterocutaneous fistulae from postoperative suture abscesses solely by diagnostic imaging in patients with Crohn's disease. The aim of this study was to examine whether use of intraintestinal administration of indocyanine green (ICG) could differentiate the conditions.

METHODS

Twenty-four patients with Crohn's disease and a possible enterocutaneous fistula at the abdominal wall based on manifestations of pus drainage and exudate were enrolled. A positive test was defined by macroscopic confirmation of staining by ICG dye, which had been administered orally, on the gauze dressing applied to the lesion site.

RESULTS

Positive responses occurred in 16 of the 24 patients. In 13 of the 16 positive patients, a fistulous communication between the lesion and the gastrointestinal tract was documented by either surgery or X-ray examination. In the remaining three, fistulae were completely closed after administration of infliximab. The positive predictive value of the oral ICG test was 16/16 (100%). Six of the eight negative oral ICG test patients (75%) had subcutaneous (silk-suture) abscesses that were easily closed following fistulotomy. The other two patients had fistulas confirmed either by surgery or fistulography, indicating a false negative response from the oral ICG test. The negative predictive value of the oral ICG test was 6/8 (75%); thus, the ability of the oral ICG test to correctly diagnose was 22/24 (92%).

CONCLUSIONS

This oral ICG test offers a suitable methodology for those patients possessing an occult fistulous lesion at an early stage, and where a differential diagnosis is difficult using diagnostic imaging.

Long-term survival from gastrocolic fistula secondary to adenocarcinoma of the transverse colon

Background

Gastrocolic fistula is a rare presentation of both benign and malignant diseases of the gastrointestinal tract. Malignant gastrocolic fistula is most commonly associated with adenocarcinoma of the transverse colon in the Western World. Despite radical approaches to treatment, long-term survival is rarely documented.

Case presentation

We report a case of a 24-year-old woman who presented with the classic triad of symptoms associated with gastrocolic fistula. Radical en-bloc surgery and adjuvant chemotherapy were performed. She is still alive ten years after treatment.

Conclusions

Gastrocolic fistula is an uncommon presentation of adenocarcinoma of the transverse colon. Radical en-bloc surgery with adjuvant chemotherapy may occasionally produce long-term survival.

The role of endoscopy in the evaluation of fistulizing Crohn's disease

Fistulas in Crohn's disease are classified as internal fistulas, for example, enteroenteric, enterovesical, rectovaginal, and external fistulas, for example, enterocutaneous, perianal, and parastomal. Although radiographic contrast studies are superior to endoscopy for diagnosing fistulas, endoscopic procedures have a definite role in the evaluation and management of fistulizing Crohn's disease. Endoscopy allows for tissue sampling, and provides information regarding the extent and severity of gastrointestinal inflammation, and the presence of such complications as strictures and cancer. Preoperative colonoscopy has particular value in assessing an enterocolonic fistula, and has important implications regarding the type of surgery performed. Endoscopic therapy for Crohn's fistula is less certain, but may allow for dilation of associated strictures, and may someday serve as a better delivery system for targeted anticytokine and immunologically based therapy.

Crohn's disease of the small bowel

Crohn's disease of the small bowel frequently requires surgical intervention. While dealing with the disease complications that require intervention, treatment should be based on a long-term strategic plan that recognizes the likelihood of recurrent disease, repeat surgeries, and the possibility of a future ostomy. Resection forms the basis for surgical treatments, but strictureplasty, abscess drainage, intestinal and diversion bypasses also are used, selectively.

Treatment of fistulizing Crohn's disease

The appropriate treatment of patients with fistulas in the setting of Crohn's disease requires a knowledge of the specific medical and surgical literature of fistulizing Crohn's. The patient with symptomatic fistulizing Crohn's disease may respond differently to specific medical therapy than a patient with symptomatic obstructing Crohn's disease. Certain medications that are useful for the treatment of patients with obstructive Crohn's disease may not be helpful in the treatment of fistulas in patients with fistulizing Crohn's disease (e.g., corticosteroids and mesalamine); in fact, some medications are believed to be detrimental (e.g., corticosteroids). Few studies have been performed to assess the efficacy of specific medications on fistulas directly. To date, there has been only one published prospective randomized controlled trial that was designed to assess the efficacy and safety of a specific medication on fistulas in patients with Crohn's disease; it showed clinical efficacy over placebo in a statistically significant manner. The judicious use of surgery remains an integral part of the management of certain presentations of fistulizing Crohn's disease, and the appropriate integration of surgical and medical therapy is of paramount importance in the management of these patients. This review provides an overview of pertinent medical and surgical literature as it pertains to management of patients with fistulizing Crohn's disease.

Clinical subtypes of Crohn's disease according to surgical outcome

Patients with Crohn's disease are typically classified into perforator or nonperforator groups. The perforator group includes those who present with acute perforation, fistulas, or abscess formation. The nonperforator group presents with stricture, obstruction, or unresponsiveness to medical therapy. Our purpose was to investigate whether perianal disease constitutes a separate predictor of surgical outcome. The form of presentation was classified as perforator, nonperforator, or perianal disease in 91 patients undergoing 232 operations for Crohn's disease. Those with perforating complications presented with the highest Crohn's Disease Activity Index, followed by those with nonperforating complications, and then the perianal disease group. However, the perianal disease group appeared to have the most rapid rate of recurrence and subsequent surgery, followed next by the perforator, and then the nonperforator group. Recurrence rate and subsequent operation intervals for the perforator group appeared to lengthen when those patients were treated with steroids and/or immunosuppressants, as compared to nonsteroidal and/or antimicrobial agents. Recurrence rate and subsequent operation intervals appeared to lengthen for the nonperforator and perianal disease groups when they were treated with nonsteroidal and/or antimicrobial therapy, as compared to steroids and/or immunosuppressants. Our data indicate that perianal disease, as a form of presentation of Crohn's disease, has independent predictive value, although this is not accurately reflected by the Crohn's Disease Activity Index.

A more liberal approach to the surgical treatment of Crohn's disease

BACKGROUND

Surgery for Crohn's disease is not intended for cure, but rather to relieve symptoms and treat complications. Perioperative morbidity, the fear of creating short bowel syndrome, and the tendency of the disease to recur convinced many physicians to refer their Crohn's patients for surgery only when life-threatening complications occur.

METHODS

This is a retrospective analysis of 47 patients operated on for Crohn's disease between 1989 and 1994. Twenty-six patients were operated on for "classic" indications ("classic" group) and the other 21 were operated on to improve their quality of life ("quality" group).

RESULTS

There was no operative or postoperative mortality during a mean follow-up period of 50 (27 to 84) months. All major postoperative complications occurred only in patients operated on for the classic indications (four abscesses, two fistulas, one wound dehiscence, and two small bowel obstructions). During the follow-up period, a total of 13 patients (50%) in the classic group and only 5 patients (24%) in the quality group required reintroduction of medical therapy or additional operations for exacerbations and complications of Crohn's disease.

CONCLUSIONS

Our data suggest that surgical intervention intended to improve the quality of life for Crohn's disease patients is safe and effective for carefully selected patients. It does improve quality of life, may prevent life-threatening complications, and offers a lower recurrence rate following surgery.

Surgical recurrence of perforating and nonperforating Crohn's disease. A study of 101 surgically treated Patients

PURPOSE

This is a study of the long-term course of surgically treated Crohn's disease designed to identify prognostic factors predictive of the time course and probability of surgical recurrence.

PATIENTS AND METHODS

The study is based on the records of 101 patients admitted to our institution for surgical treatment of Crohn's disease from January 1, 1970 to December 31, 1985. Follow-up was complete in 97 (96 percent) and incomplete in 4 patients. Median follow-up from the date of first operation was 13.25 years. The cumulative probability of requiring surgical treatment for recurrent disease was calculated using the life table method and further analyzed with the log-rank test and Cox regression.

RESULTS

The time to reoperation in this series was not significantly influenced by sex, age at onset of symptoms, age at diagnosis, age at first operation, anatomic location, and number of sites involved at the time of first operation. The only variable that had a statistically significant effect on the time to reoperation was characterization of disease at the time of operation as being perforating (P) opposed to nonperforating (NP). Median interval between the first and second intestinal operation was 1.7 years for the P group and 13 years for the NP group (P value, 0.005), and the median time between any two operations undergone during the study period was 2 years for the P group and 9.9 years for the NP group (P = 0.0002). The risk of having to undergo reoperation for recurrence was greatest during the first two years after an operation, and this was mainly because of a short time to surgical recurrence in the P group of indications. Therefore, the yearly hazard of requiring further surgery was maintained at approximately 5 percent.

CONCLUSION

The cumulative probability of requiring a reoperation for patients undergoing surgery for the P type of Crohn's disease is significantly different from that of patients with NP indications. The risk of having to undergo further surgery is particularly high during the first two years following an operation for perforating disease. The concept of a relatively aggressive perforating type of Crohn's disease and a more indolent nonperforating type is confirmed by the results of this study.

Surgical management of ileosigmoid fistulas in Crohn's disease: role of preoperative colonoscopy

PURPOSE

Surgical treatment of ileosigmoid fistulas in Crohn's disease remains controversial and can be radical (resection of both segments) or conservative (ileal resection with suture or wedge resection of the sigmoid). At our institution, the sigmoid defect is sutured if the sigmoid is not affected by primary Crohn's disease or by important stricture; otherwise, the sigmoid is resected. We reviewed our experience to evaluate our results with this procedure.

METHODS

Thirty patients with ileosigmoid fistulas underwent operation. Among them, 15 had a preoperative colonoscopy, whereas others had no endoscopic work-up. In nine patients, the sigmoid was thought to be affected by Crohn's disease (n = 7) or stricture (n = 2) and was resected. In 21 patients, the sigmoid was thought to be affected by proximity, and a simple suture (n = 15) or wedge resection (n = 6) was performed. Eleven patients had a temporary stoma (37 percent). One had coloprotectomy.

RESULTS

One patient died postoperatively. One patient had postoperative sigmoidocutaneous fistula after conservative treatment. Histology of the sigmoid specimen showed Crohn's disease in 8 patients (27 percent), including 5 of 9 resected specimens, and 3 of 21 conservative procedures. All patients with Crohn's misdiagnosis did not have preoperative colonoscopy. Nine of 11 stomas were closed in a median delay of four months. With a median delay of nine years, four patients have again undergone surgery for recurrent colonic Crohn's disease, all of whom underwent surgery initially without preoperative colonoscopy.

CONCLUSION

Preoperative endoscopic assessment of the colon is a reliable guide to use when choosing between sigmoid resection or a conservative approach and can result in reduced morbidity and improved long-term results.

Endoscopic and external bowel changes and histopathology in patients with Crohn's disease

The relationships between intraoperative endoscopic findings, exterior bowel wall changes and transmural histopathology were investigated in 23 patients with Crohn's disease (24 resections). Villous atrophy and leucocyte infiltration of the epithelium, lamina propria and submucosa were common in intestine without endoscopic lesions. Minor endoscopic ulcers were associated with leucocyte infiltration, ulcers and pyloric metaplasia, and large endoscopic ulcers and stricture with severe transmural inflammation, fibrosis and fissures. In ileal Crohn's disease (19 resections), correlation was close between endoscopic stage and histopathology (rs = 0.77, P < 0.0001), but an exterior lesion index showed worse correlations with endoscopy and histology (rs = 0.57 and rs = 0.59 respectively). The difference was attributable to patients with previous resection and/or fistula showing exterior lesions without concomitant histological or endoscopic abnormalities. Intraoperative surgical decisions should be guided by endoscopic observations rather than by assessment of exterior bowel wall changes.

Surgical treatment of inflammatory bowel disease

Surgery continues to play an important role in the overall treatment strategy for patients with Crohn's disease and ulcerative colitis. Innovative techniques have greatly facilitated the operative approach in patients with both disorders.

Intraoperative enteroscopy in Crohn's disease

Intraoperative small bowel endoscopy was performed on 33 occasions in 31 patients with Crohn's disease. The extent of mucosal inflammation was compared with that of changes in the external bowel wall: serositis, fat-wrapping and mural thickening. The influence of endoscopic findings on surgical management was evaluated. Mucosal inflammation was generally more extensive than serositis (P < 0.01), but less so than mural thickening (P < 0.001). The extent of fat-wrapping did not differ from that of mucositis. Of 23 patients undergoing reoperation or with fistula or abscess, however, eight had serositis and/or fat-wrapping in bowel segments without mucosal inflammation. Endoscopic findings influenced surgical decisions on 20 of the 33 occasions, limiting planned resection in 14, identifying strictures for repair in one, and deciding against resection in two cases and for extended resection in three. These results suggest that external inflammatory changes are unreliable guides to the extent of intestinal mucositis and requirements for resection in Crohn's disease. By visualizing the mucosa, intraoperative enteroscopy can provide information for more precise surgery, thereby limiting resection.

Crohn's disease and carcinoma: increasing justification for surveillance?

Carcinoma of the colon that arises in patients with Crohn's disease is being reported with increasing frequency. To help clarify the nature of this association, records of 25 patients with Crohn's disease and colorectal carcinoma seen from 1957 through 1989 were reviewed. One patient had leiomyosarcoma of the rectum, and two patients had the onset of Crohn's disease after the diagnosis and treatment of colorectal carcinoma. Therefore, 22 patients were available for complete retrospective analysis. The median age at diagnosis of Crohn's disease was 37 years (range, 15-67 years), and the median age at diagnosis of carcinoma was 54.5 years (range, 32-76 years). The median duration of symptoms preceding the discovery of colorectal carcinoma was 18.5 years (range, 0-32 years). Carcinoma arose in colonic segments with known Crohn's disease in 77 percent of patients, and six patients (27 percent) had associated colonic mucosal dysplasia. One lesion was classified as Dukes A, nine lesions were Dukes B, five lesions were Dukes C, and seven lesions were Dukes D. Patients with an onset of Crohn's disease before the age of 40 years had primarily Dukes C or D lesions and consequently poor survival. Most patients presented with nonspecific signs and symptoms, with nothing to distinguish the activity of the Crohn's disease from the presence of colorectal neoplasm. Younger patients with long-standing Crohn's disease should be considered for colonic surveillance to permit earlier diagnosis and treatment of potential colorectal carcinoma.

Surgical repair of rectovaginal fistulas in patients with Crohn's disease: transvaginal approach

The surgical management of rectovaginal fistulas complicating Crohn's disease has been associated with unacceptably high failure rates. We sought to modify the available surgical techniques to provide a solution to this challenging problem. Between December 1983 and January 1990, 14 patients with Crohn's disease underwent repair of a rectovaginal fistula. A modified transvaginal approach was employed by the authors. A diverting loop ileostomy was performed on all patients, either as the initial step in the staged management of intractable perianal disease or concurrent with the repair of the rectovaginal fistula. The fistula was completely eradicated in 13 of the 14 women and did not recur during the mean follow-up period of 55.0 months (range, 3-77 months). Intestinal continuity was reestablished in these 13 patients within 6 months after the initial fistula repair. One patient with a very low-lying fistula constituted our only failure. We have found the transvaginal method preferable to the transanal approach because of the relative ease in raising the vaginal flap as compared with a flap of fibrotic and inflamed anorectal mucosa. On the basis of this study, we conclude that a modified transvaginal approach is an effective method for repair of rectovaginal fistulas secondary to Crohn's disease.

Transvaginal approach for repair of rectovaginal fistulae complicating Crohn's disease

The management of rectovaginal fistulae complicating Crohn's disease is difficult and often unsatisfactory. Between December 1983 and November 1988, 13 patients with Crohn's disease underwent repair of rectovaginal fistulae via a transvaginal approach. All patients had a diverting intestinal stoma either as part of the initial step in the staged management of intractable perianal disease or concurrent with the repair of the rectovaginal fistula. Each of the patients had low or mid septal fistulae; high fistulae generally are treated transabdominally and are not the focus of this discussion. Fistulae were eradicated in 12 of the 13 women and did not recur during the follow-up period, which averaged 50 months (range, 9 to 68 months). The only treatment failure was a patient who had a markedly diseased colon from the cecum to the rectum and a very low-lying fistula. It is concluded that a modified transvaginal approach is an effective method for repair of rectovaginal fistulae secondary to Crohn's disease.