Incidence, diagnosis, and treatment of enteric and colorectal fistulae in patients with Crohn's disease

Surgical outcomes in ileal Crohn's disease complicated by ileosigmoid fistula

BACKGROUND

The management of Crohn's disease (CD) complicated by ileosigmoid fistula (ISF) remains a challenge, and Australian outcomes have not previously been reported.

METHODS

A retrospective review of a tertiary colorectal inflammatory bowel disease unit, across public and private sites, from 2005 to 2023 to identify adult patients having undergone operative management of ISF.

RESULTS

Twenty-nine patients underwent surgery for ISF in the study period. Seventeen were male and the median age was 40 years. The pre-operative diagnosis of ISF was made in 76%, and patients were more likely to undergo resectional surgery if the pre-operative diagnosis was made endoscopically. Sixty-nine percent of cases were performed electively, with 76% completed laparoscopically with an 18.5% conversion rate to an open approach. The ISF was oversewn in three patients, repaired primarily in 14 patients, managed with segmental wedge resection in eight patients and resected via an anterior resection in four patients. The rate of stoma formation at the index procedure was 20.7% overall and 22% in patients being acutely managed with steroids. Emergent cases were more likely to be defunctioned with a stoma. Morbidity was 17.2% with a single anastomotic leak.

CONCLUSION

ISF in CD remains difficult to diagnose pre-operatively, but can be safely managed laparoscopically without formal resection, and with limited use of diverting stoma formation. The specific surgical approach to the sigmoid in ISF is difficult to pre-determine and often requires decisions to be made intra-operatively.

Long-term outcomes of intestinal penetrating Crohn's disease following successful nonoperative management

There is a paucity of data on the surgical or medical treatment for abscess/fistula complicating Crohn's disease after successful nonsurgical management. We conducted a cohort study to investigate the long-term outcomes and the risk factors for the requirement of subsequent surgical intervention in Crohn's disease patients with complicating fistulas/abscess following successful nonsurgical management. Data were collected on penetrating Crohn's disease experiencing successful nonsurgical treatment between December 2012 and December 2021. Long-term outcomes and risk factors of surgery were assessed by univariate and multivariate analysis, and subgroup analysis was performed based on penetrating phenotype including abscess, fistula, and phlegmon. A total of 523 penetrating Crohn's disease patients; there were 390, 125, and 60 patients complicated with fistulas, abscess, and phlegmon, respectively. Long-term outcomes showed that BMI < 18.5 (kg/m 2 ), the recurrent abscess, and stricture were independent risk factors of surgery. Biologics and resolution of abscess were independent protective factors of surgery. Furthermore, in 399 patients undergoing early surgery, stricture and BMI < 18.5 (kg/m 2 ) were independent risk factors, and biologics and abscess resolution were protective of the early surgery. Subgroup analysis based on fistula, abscess, and phlegmon phenotype also demonstrated that concomitant stricture was an independent risk factor and the use of biologics was protective of surgical resection. Our data indicate that biologics can delay the requirement of surgery and may be given to patients with penetrating complicating Crohn's disease who have been successfully treated nonoperatively, but surgical resection should be considered in the setting of malnutrition and stenosis formation.

Enterovesical Fistula Revealing Crohn's Disease: A Case Report

Crohn's disease is an inflammatory bowel disease of unknown etiology. It is characterized by intra- and extra-intestinal complications. It is a frequent cause of uroenteric fistulas. They are mostly symptomatic and occur after several years of the evolution of Crohn's disease. The pneumaturia and fecaluria are the most significant symptoms for their presence. They are usually poorly tolerated and require surgical treatment. We report the case of an enterovesical fistula revealing Crohn's disease during endoscopic resection of a bladder pseudotumor in a generally impaired patient. Crohn's disease should be evocated when histology is not relevant for a bladder pseudotumor or a rectovesical fistula. The discovery of an isolated bladder pseudotumor should suggest the diagnosis in the context of weight loss and chronic diarrhea. Enterovesical fistulas are uncommon but potentially dangerous complications of Crohn's disease. Abdominal CT scans and cystoscopy are the most commonly used diagnostic modalities. Surgical treatment seems to be unavoidable in most cases although medical treatment could also benefit a small cohort of patients.

Gastric and Duodenal Fistulas in Crohn's Disease, a Surgical Challenge: Report of 5 Cases and a Review of the Literature

BACKGROUND Fistulas involving the stomach and duodenum in Crohn's disease are rare (occurring in less than 1% of patients). Here, we reviewed registers from 855 patients with Crohn's disease treated in our service from January 2007 to December 2020 and found 4 cases of duodenal fistula and 1 case of gastric fistula. CASE REPORT The fistula origin was in the ileocolic segment in all cases, and all of the patients underwent preoperative optimization with improvement of nutritional status and infection control. They then underwent surgical treatment with resection of the affected segment and duodenal or gastric closure with covering by an omental patch. One case of a duodenal fistula was complicated by duodenal dehiscence. This was treated surgically with duodenojejunostomy. Each of the other patients had an uneventful postoperative course. All patients were successfully cured of their gastroduodenal fistulas, and at the time of this publication, none of them died or had fistula recurrence. CONCLUSIONS Fistulas with the involvement of the stomach and duodenum in patients with Crohn's disease are almost always due to inflammation in the ileum, colon, or previous ileocolic anastomosis. Management of this situation is complex and often requires clinical and surgical assistance; preoperative optimization of the patient's general condition can improve the surgical results. The surgical approach is based on resection of the affected segment and gastric or duodenal closure with covering by an omental patch. Gastrojejunostomy or duodenojejunostomy can be performed in selected patients with larger defects and minor jejunal disease. To prevent recurrence, prophylactic therapy with anti-TNF agents and early endoscopic surveillance are also essential for successful treatment.

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.

Diagnosis and Classification of Fistula from Inflammatory Bowel Disease and Inflammatory Bowel Disease-Related Surgery

Fistula in inflammatory bowel disease (IBD) is a well-known yet poorly understood phenotype. Pathophysiology is largely based on the activation of the epithelial-mesenchymal transition (EMT); however, interactions with the microbiome, genetics, mechanical stress and the presence of stricturing disease, and surgical complications play a role. Perianal penetrating disease represents a more severe phenotype in IBD. Pouch-associated fistula can arise as a result of an anastomotic leak, surgical complications, or Crohn's disease (CD) of the pouch. Classification is site-dependent, includes a range of severity, and informs management. It is important to determine associated symptoms and recognize the complex interplay of underlying etiologies to form the basis of appropriate care.

Surgical Management of Crohn's Disease

Treatment of Crohn's disease (CD) focuses on providing acceptable quality of life for the affected individual by optimizing medical therapy, endoscopic procedures, and surgical intervention. Biologics have changed the medical management of moderate to severe CD. However, despite their introduction, the need for surgical resection in CD has not drastically changed, with two-thirds of the patients still requiring an intestinal resection. Patient outcomes are optimized by focusing on preoperative management and intraoperative technical aspects to maximize bowel preservation. This article reviews some of the important principles of Crohn's surgery to help guide surgeons when approaching this challenging patient population.

Surgical Planning in Penetrating Abdominal Crohn's Disease

Crohn's disease (CD) is increasing globally, and the disease location and behavior are changing toward more colonic as well as inflammatory behavior. Surgery was previously mainly performed due to ileal/ileocaecal location and stricturing behavior, why many anticipate the surgical load to decrease. There are, however, the same time data showing an increasing complexity among patients at the time of surgery with an increasing number of patients with the abdominal perforating disease, induced by the disease itself, at the time of surgery and thus a more complex surgery as well as the post-operative outcome. The other major cause of abdominal penetrating CD is secondary to surgical complications, e.g., anastomotic dehiscence or inadvertent enterotomies. To improve the care for patients with penetrating abdominal CD in general, and in the peri-operative phase in particular, the use of multidisciplinary team discussions is essential. In this study, we will try to give an overview of penetrating abdominal CD today and how this situation may be handled. Proper surgical planning will decrease the risk of surgically induced penetrating disease and improve the outcome when penetrating disease is already established. It is important to evaluate patients prior to surgery and optimize them with enteral nutrition (or parenteral if enteral nutrition is ineffective) and treat abdominal sepsis with drainage and antibiotics.

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.

Enterosalpingeal fistula complicating Crohn's disease: Report of two cases and review of the literature

Introduction and importance

Reports of enterosalpingeal fistulae complicating Crohn's disease are scarce. They involve the last ileal loop and lead to a progressive destruction of the salpinx. Usually, no genital symptoms are found. In all the cases reported in the literature, the fistula was diagnosed intra-operatively and resection of the right salpinx was performed without the patient's pre-operative consent.

Case presentation

We describe 2 cases of women presenting with an Enterosalpingeal fistulae complicating Crohn's disease. Radiological findings allowed a pre-operative diagnosis. Thus, the patients were warned of the right salpinx resection and consent was obtained.

Clinical discussion

Enterosalpingeal fistulae complicating Crohn's disease are exceptional. Indeed, to the best of our knowledge, only five cases have been reported till now. In all the reported cases, no genital signs were present. As for our patients who didn't experience such symptoms. Moreover, no radiological evidence of the enterosalpingeal fistula was found in the literature. Consequently, the fistula was always diagnosed intra-operatively. For our patients, radiological findings allowed a pre-operative diagnosis. This permitted to warn them of a possible resection of the fallopian tube. Intra-operative findings were unfortunately conflicting with its preservation.

Conclusion

Enterosalpingeal fistula is an exceptional complication of the Crohn's disease. No clinical findings are present. The diagnosis should be evoked when the CT-scan or the MRI show an abnormal apposition between the fallopian tube, the last loop and the cecum. Surgical resection of the involved salpinx with the diseased intestinal segment is unfortunately usually needed in a young patient population.

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Report of two cases of an unusual form of Crohn's disease.

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Unique preoperative imaging.

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Preoperative diagnosis of the fistulae. Thus, patients were warned of salpingectomy.

Adjunctive Hyperbaric Oxygen Therapy in Refractory Crohn's Disease: An Observational Study

Background and Aims

Patients may experience complications of Crohn's disease (CD) even when treated with optimal medical therapy strategies. Previous data have shown the efficacy of hyperbaric oxygen therapy (HBOT) in the management of complicated CD. However, there is no consensus regarding the optimal number of sessions or duration of treatment regimens. The aim of the present study was to investigate the efficacy of HBOT in CD patients who were refractory to conventional medical management.

Methods

This study included patients who underwent HBOT for the treatment of the following complications: perianal fistulizing Crohn's disease (pCD), enterocutaneous fistulas (ECF), or pyoderma gangrenosum (PG). Complete healing was defined as the closure of external orifice and the absence of active draining (in pCD), complete wound healing (in PG), and granulation or complete wound epithelialization with no enteric draining (in ECF). The persistence of draining and the absence of wound granulation were defined as incomplete healing.

Results

Forty patients were included. The mean CD duration was 10.6 ± 5.8 years. pCD comprised most of the included patients (25/62.5%), followed by ECF (n = 13/32.5%) and PG (n = 6/15%). In two patients (5%), a combination of ECF and PG was diagnosed, and in one patient (2.5%), all three complications were observed. A total of 32 patients (82.5%) had complete healing. Patients with PG had the highest healing rates (100%), followed by those with ECF (84.6%) and pCD (80%).

Conclusions

Adjunctive HBO was associated with significant healing rates for CD-associated complications such as pCD, ECF, and PG.

Nutrition Management of the High-Output Fistulae

Enterocutaneous fistulae (ECFs) are commonly encountered complications in medical and surgical practice. High-output fistulae are associated with significant morbidity and mortality, poor quality of life, and a substantial healthcare burden. An interdisciplinary team approach is crucial to prevent and mitigate the adverse clinical consequences of high-output ECFs including sepsis, metabolic derangements, and malnutrition. Patients with ECFs are at a significantly higher risk of developing malnutrition and close monitoring by nutrition support professionals and/or a nutrition support team is an essential component of their medical management. High-output ECFs often require the initiation of nutrition support through either enteral or parenteral routes. Historically, parenteral nutrition (PN) has been the primary method of nutrition support in these patients. However, oral and enteral nutrition (EN) should remain viable options if an evaluation of the location of the ECF, amount of remaining functional bowel, and volume of ECF output identifies favorable conditions. Additionally, in contrast to PN, oral nutrition and EN are the preferred method of feeding because of the maintenance of the structural and functional integrity of the gastrointestinal tract. The inclusion of pharmacological interventions can greatly assist with the reduction and stabilization of ECF output and thereby permit sustained enteral feeding. Initiation of supplemental or full PN will be required if oral nutrition and EN lead to metabolic derangements, fail to meet energy requirements, or do not maintain or improve the patient's nutrition status. The main focus of this review is to discuss the nutrition management of patients with high-output ECFs.

Drain site enterocutaneous fistula after hyperthermic intraperitoneal chemotherapy

Spontaneous sigmoid colon perforation after cytoreduction surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is a rare complication. It is more commonly seen with mitomycin‐based HIPEC. This case study's patient presented with pus discharge at the drain site after 4 weeks of surgery. The symptoms persisted after conservative treatment. High suspicion after the feculent smell of the discharge fluidled to the prompt diagnosis of enterocutaneous fistula. There was limitedperforation with abscess formation, followed by fistula formation. The patient was treated successfully with surgery.

The impact of enteric fistulas on US hospital systems

BACKGROUND

There is limited characterization of patients with enteric fistula. Our objective is to determine the incidence of the disease, and characterize demographics, healthcare costs, co-diagnoses, and procedures in this population.

METHODS

The National Inpatient Sample database 2004-2014 was queried to identify patients with enteric fistula using ICD-9 code 569.81.

RESULTS

There were 317,000 admissions with a diagnosis of enteric fistula from 2004 to 2014, accounting for 230,000 hospital days annually. Costs totaled $500 million with charges of $1.5 billion annually. Inpatient mortality is 4.1%. Patients had significant comorbidities and 3 procedures or surgical interventions per admission.

CONCLUSIONS

This descriptive study elucidates the impact of enteric fistula on patients and hospitals by characterizing incidence, clinical associations, and admission characteristics. There is significant financial impact with 28,000 admissions and $500 million dollars in annual costs. This study lays the groundwork for future research by characterizing the impact of enteric fistula.

Salpingo Enteric Fistula: A Case Report

Background

Few cases with fistulous communication between the GI system and female adnexal structure have been reported in the literature, and bilateral contrast spillage has been reported only in one case, and this case is the second one all over the world.

Case Presentation

The case was a 27-year-old woman with a diagnosis of primary infertility. She was booked with hysterosalpingogram (HSG) as part of the routine workup in the infertility clinic. There was a positive history of pelvic surgery for bilateral adnexal cysts for her in 2014. In this case, previous pelvic surgery without any medical problems was the strongest risk factor for tubo-intestinal fistula. Cystectomy performed for the left adnexal cyst and the right adnexal cyst was only drained. The pathologic report for the left ovarian cyst was endometriosis. HSG result showed evidence of bilateral fallopian tube opacification with contrast outlining from the fallopian tubes. Contrast leakage happened to the adjacent small intestine in the right side and peritoneal cavity on the left side.

Conclusion

Fistulous connections between fallopian tube and intestine will remain an exceptional rarity. The reported case could be a good lesson illustrating that the adherence to general surgical principles (meticulous hemostasis, careful applying of diathermy, etc.) and a watchful postoperative care could protect the patient from both usual and unusual complications.

Crohn's disease: prevalence, MR features, and clinical significance of enteric and colonic sinus tracts

Objectives

Enteric and colonic sinus tracts are inflammatory complications that precede intestinal fistulas in patients with Crohn’s disease (CD). The aim of this study was to retrospectively determine the prevalence, morphologic features, and outcome of sinus tracts using MR imaging.

Methods

A consecutive cohort of 642 patients with known CD, referred for MR enterography or MR enteroclysis (study period 01/2014–09/2019), was evaluated retrospectively for the presence of sinus tracts, their locations, presence and length of coexisting strictures, bowel wall thickness, CDMI score, upstream dilation, and bowel distension. Clinical outcome was assessed using medical records. For metric data, means and standard deviation, as well as one-way ANOVA and Pearson’s correlation coefficient, were calculated.

Results

In 36/642 patients with CD undergoing MRE, 49 sinus tracts (forty in small intestine, nine in left-sided colon) were detected with a prevalence of 6.9% in patients with MR-visible signs of CD (n = 519, overall prevalence of 5.6%). Mean segmental bowel wall thickness was 8.9 mm, and mean CDMI score was 9.3. All sinus tracts were located within a stenotic segment, showing mesenteric orientation within the small bowel and upstream dilation in 13 patients. Of 36 patients, 19 underwent immediate surgery and seven developed clinical progression within the segment containing the sinus tract.

Conclusions

Sinus tracts occur in 6.9% of patients with visible signs of CD. They are located within stenotic, severely thickened bowel segments with high MR inflammation scores. Their detection is clinically important, because they indicate a more aggressive phenotype and, if left untreated, may show severe progression.

Key Points

• Sinus tracts occur in 6.9% of patients with MR-visible signs of Crohn’s disease.

• Sinus tracts are a radiological indicator of early penetrating Crohn’s disease, with a high risk of progression, and require dedicated treatment.

• Sinus tracts can be recognized by characteristic findings and typically occur in stenotic, severely thickened bowel segments with high MR inflammation scores.

Gastrocolic fistula in Crohn’s disease detected by oral agent contrast-enhanced ultrasound: A case report of a novel ultrasound modality

BACKGROUND

Fistulas are common complications of Crohn’s disease (CD). Gastrocolic fistulas (GFs) are rare, occult and potentially life-threatening complications. Few cases of GFs have been reported. Oral agent contrast-enhanced ultrasound (OA-CEUS) is a novel technique of ultrasound (US) for gut. Contrast agent made by Chinese yam is taken orally to dilate the lumen of the upper gastrointestinal tract. Thus, the impediment of gas inside gastrointestinal tract is removed and a good acoustic window is provided for gastroin-testinal tract scanning. This paper describes a case of GF secondary to CD detected by OA-CEUS when it was missed by endoscopy and computed tomography (CT). To our knowledge, this is the first report of GF secondary to CD detected by OA-CEUS up to date.

CASE SUMMARY

A 29-year-old woman with a 6-year history of CD was admitted to our hospital for abdominal pain and diarrhea for 5 months without obvious predisposing causes. Initial gastroscopy failed to show any evidence of lesions. Colonoscopy revealed multiple erosions, mucosal nodularity, linear ulcers and a cobblestone appearance. A CT scan of her abdomen showed a complex multilocular structure adherent to the greater curvature of the stomach in her left lower abdomen, with fluid, gas and significant surrounding inflammation. CT also demonstrated an abdominal abscess, which was later treated with US-guided drainage. Colonoscopy, gastroscopy and CT missed the presence of a GF. OA-CEUS was performed. A contrast agent made from Chinese yam was taken orally to dilate the lumen of the gastrointestinal tract. A good acoustic window was provided for gastrointestinal tract scanning and the impediment of gas inside the gastrointestinal tract was removed. With the aid of the “window”, a canal with hypoechoic wall was identified connecting the greater curvature of stomach to the splenic colon flexure in free sections. We also observed the hyperechoic gas flowing dynamically inside the canal. Thus, a GF was suspected. US is the first imaging modality taking GF into account. At the same time, OA-CEUS identified the site of the fistula and its two orifices. Gastroscopy was performed again, revealing a small ulcer approximately 5 mm in diameter, which was considered as an orifice. On the basis of OA-CEUS and other examinations, the patient was diagnosed with a GF secondary to CD. Then, laparoscopic exploration, partial stomach resection, transverse colostomy and abdominal abscess drainage were performed. The patient recovered uneventfully.

CONCLUSION

GFs are rare, occult and potentially life-threatening complications in CD. US is one of the first-line modalities to evaluate CD and its complications. OA-CEUS, a novel technique of US for gut, may be helpful in reducing the possibility of a missed diagnosis of GF.

Intraoperative inspection alone is a reliable guide to the choice of surgical procedure for enteroenteric fistulas in Crohn's disease

Background/Aims

Resection of the diseased segment and suture of the victim segment is recommended for enteroenteric fistula in Crohn's disease (CD). The main difficulty in this procedure remains reliable diagnosis of the victim segment, especially for fistulas found intraoperatively and inaccessible on endoscopic examination. We aimed to explore whether intraoperative inspection alone is reliable.

Methods

Patients undergoing conservative surgery between 2011 and 2016 for enteroenteric fistulas complicating CD were identified from a prospectively maintained database. Patients were divided according to whether the victim segment was evaluated by preoperative endoscopy + intraoperative inspection (PI group) or by intraoperative inspection alone (I group). Outcomes were compared.

Results

Of 65 patients eligible for the study, 37 were in in the PI group and 28 were in the I group. The baseline characteristics were similar between the groups, except for the rate of emergency surgery (0/37 in PI group vs. 5/28 in I group, P=0.012). Fistulas involved more small intestines (4/37 in PI group vs. 15/28 in I group, P<0.001) and fewer sigmoid colons (17/37 in PI group vs. 4/28 in I group, P=0.008) in I group due to accessibility with endoscopy. No difference was found in postoperative complications, stoma rates, postoperative recurrence, or disease at the repair site between the 2 groups (P>0.05).

Conclusions

For fistulas found intraoperatively and inaccessible on endoscopic examination, intraoperative inspection was a reliable guide when choosing between en bloc resection and a conservative procedure.

The Management of Intestinal Penetrating Crohn's Disease

Crohn's disease (CD) leads to the development of complications through progressive uncontrolled inflammation and the transmural involvement of the bowel wall. Most of the available literature on penetrating CD focuses on the perianal phenotype. The management of nonperianal penetrating complications poses its own set of challenges and can result in significant morbidity and an increased risk of mortality. Few controlled trials have been published evaluating this subgroup of patients for clinicians to use for guidance. Utilizing the available evidence, we review the epidemiology, presentation, and modalities used to diagnosis and assess intestinal fistulas, phlegmons, and abscesses. The literature regarding the medical, endoscopic, and surgical management options are reviewed providing physicians with a therapeutic framework to comprehensively treat these nonperianal penetrating complications. Through a multidisciplinary evidence-based approach to the complex sequela of CD outcomes can be improved and patient's quality of life enhanced.10.1093/ibd/izx108_video1izx108_Video5754037501001.

Genital and reproductive organ complications of Crohn disease: technical considerations as it relates to perianal disease, imaging features, and implications on management

OBJECTIVE

A relatively large proportion of patients with Crohn disease (CD) develop complications including abscess formation, stricture, and penetrating disease. A subset of patients will have genital and reproductive organ involvement of CD, resulting in significant morbidity. These special circumstances create unique management challenges that must be tailored to the activity, location, and extent of disease. Familiarity with the epidemiology, pathogenesis, imaging features, and treatment strategies for patients with genital CD can aid imaging diagnoses and guide appropriate patient management. The purpose of this study is to illustrate the spectrum of CD in the genital tract and reproductive organs and discuss the complex management strategies in these patients as it relates to imaging.

CONCLUSION

Given the impact on patient outcome and treatment planning, familiarity with the epidemiology, pathogenesis, imaging features, and treatment of patients with genital Crohn disease can aid radiologic diagnoses and guide appropriate patient management.

Use of a linear stapler for the treatment of ileocolic fistula in Crohn's disease

AIM

The study reports an easy technique for surgical management of some forms of ileocolic fistula in Crohn's disease.

METHOD

Five patients with Crohn's disease with ileocolic fistula (2011-2014) have been managed by the application of linear stapler devices.

RESULTS

Postoperative course was satisfactory in all patients. At 1 year there was no evidence of stricture or fistula formation and no patient had required reoperation.

CONCLUSION

The technique is easy and effective and can be used in open and laparoscopic surgery.

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.

Challenges in the Medical and Surgical Management of Chronic Inflammatory Bowel Disease

Inflammatory bowel disease patients will likely come to the surgeon's attention at some point in their course of disease, and they present several unique anatomic, metabolic, and physiologic challenges. Specific and well-recognized complications of chronic Crohn disease and ulcerative colitis are presented as well as an organized and evidence-based approach to the medical and surgical management of such disease sequelae. Topics addressed in this article include intestinal fistula and short bowel syndrome, pouch complications, and deep venous thrombosis with emphasis placed on optimization of the patient's physiologic state for best outcomes.

Segmental sigmoid polyposis as a colonoscopic indicator of an ileosigmoid fistula in Crohn's ileitis

BACKGROUND AND AIMS

Ileosigmoid fistulas (ISFs) are frequently undiagnosed prior to surgery. This study was designed to describe a polyp or cluster of polyps limited to the sigmoid colon as a marker of ISF in patients with ileitis. This novel finding will increase a gastroenterologist's opportunity to detect them preoperatively and their prognostic implication of worsening ileitis.

METHODS

The medical records of patients with Crohn's disease and ISF were reviewed to determine whether colonoscopy had revealed polyposis limited to the sigmoid colon and its frequency.

RESULTS

Thirty-seven patients with Crohn's ileitis complicated by ISF were identified from our database. Twenty had one or more sigmoid polyps without polyps elsewhere in the colon suggesting the site of fistula exit. Fifteen of the patients had ISF and five had ileorectal fistula (IRF). The fistula was detected by various means, including colonoscopy, sigmoidoscopy, small bowel X-ray series, barium enema, computed tomography, and magnetic resonance enterography. The ISF was generally diagnosed prior to the recognition and significance of the segmental polyps. These polyps were inflammatory or hyperplastic on pathologic review.

CONCLUSION

Most ISFs and IRFs are now found preoperatively by imaging and some are incidental surgical findings. The segmental sigmoid polyps that we describe should help the gastroenterologist to be suspicious of ISF. The polyps are a surrogate marker for the progression of the fistula and the underlying ileitis as they tend to appear after the fistula has matured and lead to increased intensity of medical therapy well before surgical intervention is required.

[Vesico-sigmoid fistula complicating intestinal hydatid disease: report of a rare case]

La fistule colo-vésicale sur une hydatidose sigmoidienne est une entité pathologique exceptionnelle. Nous rapportions une nouvelle observation, ou seront rappelées les principales données diagnostique et thérapeutique de cette affection.

Surgical treatment of complex small bowel Crohn disease

INTRODUCTION

The clinical presentations of Crohn disease of the small bowel vary from low to high complexity. Understanding the complexity of Crohn disease of the small bowel is important for the surgeon and the gastroenterologist caring for the patient and may be relevant for clinical research as a way to compare outcomes. Here, we present a categorization of complex small bowel Crohn disease and review its surgical treatment as a potential initial step toward the establishment of a definition of complex disease.

RESULTS

The complexity of small bowel Crohn disease can be sorted into several categories: technical challenges, namely, fistulae, abscesses, bowel or ureteral obstruction, hemorrhage, cancer and thickened mesentery; extensive disease; the presence of short gut; a history of prolonged use of medications, particularly steroids, immunomodulators, and biological agents; and a high risk of recurrence.

CONCLUSIONS

Although the principles of modern surgical treatment of Crohn disease have evolved to bowel conservation such as strictureplasty techniques and limited resection margins, such practices by themselves are often not sufficient for the management of complex small bowel Crohn disease. This manuscript reviews each category of complex small bowel Crohn disease, with special emphasis on appropriate surgical strategy.

Successful management of a colo-duodenal fistula in a patient with Crohn's disease using a double lumen gastro-jejunostomy tube

A 41-year-old woman was admitted with upper abdominal pain, vomiting and fever. Abdominal CT scan showed a colo-duodenal fistula with inflammatory thickening of the transverse colon. The patient's general health was poor because of hypoalbuminemia and coagulopathy. Endoscopy showed a fistula at the lower duodenal angle and the stomach was filled with refluxed stool. Ileostomy and percutaneous endoscopic gastrostomy were performed at that time and a double lumen gastro-jejunostomy inserted through the gastrostomy to allow both gastric drainage and distal enteral feeding. Nutrition support was gradually converted from parenteral to enteral feeding. Colonoscopy showed stenosis of the transverse colon with a colo-colonic fistula near the stenosis. Two months later, right hemi-colectomy and closure of the colo-duodenal fistula were performed. The resected specimen showed stenosis and a fistula in the transverse colon due to Crohn's disease. The colo-colonic fistula was present and the colo-duodenal fistula had almost closed due to fibrosis. The postoperative course was uneventful and the patient was discharged after administration of infliximab. Use of a double lumen gastro-jejunostomy tube was effective in improving the patient's general condition. This therapeutic strategy allowed the safe conduct of major resection in a high-risk patient.

Differential diagnosis of intestinal tuberculosis from Crohn's disease and primary intestinal lymphoma in China

BACKGROUND/AIMS

There are many similarities and overlaps in clinical, radiological, endoscopic, and histological features among intestinal tuberculosis (ITB), Crohn's disease (CD), and primary intestinal lymphoma (PIL), and the differential diagnosis of ITB can be very challenging for clinicians.

PATIENTS AND METHODS

The clinical, radiologic, endoscopic, and pathological data of 213 patients were analyzed retrospectively. According to the diagnostic criteria and exclusive criteria of ITB, CD, and PIL, 83 patients were recruited and divided into three groups, including 30 cases in the ITB group, 38 cases in the CD group, and 15 cases in the PIL group, and the medical data and statistical analysis were recorded.

RESULTS

Rural patients with abdominal pain as the first symptom and with transverse ulcer and caseating granulomas were more common in the ITB group than the CD group, whereas urban patients with stool change as the first symptom, moderate or severe anemia, thickening of intestinal wall, rectal involvement, skipping distribution, prominent lymphoid aggregates, and irregular glands were more common in CD group than ITB group (P < 0.05). Young patients (age < 30 years) with fever, weakness, fatigue, abdominal mass, intestinal perforation, and emergent operation were more common in ITB group than PIL group, whereas thickening of intestinal wall, malignant lymphocytes, limited distribution, and involvement of small intestine occurred more in PIL group than ITB group (P < 0.05).

CONCLUSION

The differential diagnosis of ITB from CD and PIL can be made by a combination of clinical manifestation, endoscopy, and pathological examinations.

Predictive risk factors of early postoperative enteric fistula in colon and rectal surgery

Early postoperative enteric fistula (PEF) is a complication associated with a high rate of morbidity and mortality in colon and rectal surgery. We evaluated the effect of patient characteristics, comorbidities, pathology, resection type, surgical technique, lysis of adhesions, and admission type on the rate of PEF in colorectal surgery. Using the National Inpatient Sample database, we examined the clinical data of patients who underwent colon and rectal resection from 2009 to 2010. A total of 646,414 patients underwent colorectal resection during this period. Overall, the rate of PEF was 0.37 per cent (2407 patients). Using multivariate regression analysis, Crohn's disease (adjusted odds ratio [AOR], 4.68), lysis of abdominal adhesions (AOR, 4.25), open procedure (AOR, 3.18), and transverse colectomy (AOR, 2.13) significantly impacted the risk of PEF. Although teaching hospitals (AOR, 1.69), obesity (AOR, 1.40), male gender (AOR, 1.30), emergent surgery (AOR, 1.27), age older than 65 years (AOR, 1.24), and diabetes mellitus (AOR, 1.21) also had statistically significant impact on rates of PEF, these were less clinically significant than the other factors. The presence of Crohn's disease and lysis of abdominal adhesions are strongly associated with the development of PEF after colorectal surgery. Laparoscopic surgery was associated with a lower rate of PEF; further studies would be needed to evaluate the importance of this finding.

A role for tumor necrosis factor and bacterial antigens in the pathogenesis of Crohn's disease-associated fistulae

BACKGROUND

Intestinal fistulae represent a severe complication of Crohn's disease (CD). The authors have demonstrated that epithelial-to-mesenchymal transition plays a pivotal role in their pathogenesis. High levels of interleukin-13 and tumor necrosis factor (TNF) are detected in myofibroblast-like transitional cells covering the fistula tracts. Here, a functional role was investigated for the transcription factor Ets-1, TNF, and the bacterial wall component (muramyl dipeptide [MDP]) in the pathogenesis of CD-associated fistulae.

METHODS

Perianal fistulae from CD patients were analyzed by immunohistochemistry. Primary colonic lamina propria fibroblasts (CLPFs) were isolated from CD patients with or without fistulizing disease. Messenger RNA (mRNA) levels were assessed by real-time polymerase chain reaction in CLPF or HT29 intestinal epithelial cells (IECs) grown as monolayers or spheroids.

RESULTS

Strong expression of Ets-1 transcription factor was demonstrated in transitional cell covering the fistula tracts by immunohistochemistry. TNF induced mRNA expression of ETS-1 and β6-integrin in HT29 IEC and in CLPF from fistulizing CD patients. These effects could be fully blocked by administration of anti-TNF antibodies. In HT29 cells, TNF further induced mRNA levels of TNF and transforming growth factor beta by treatment for 24 hours. In fistula CLPF derived from CD patients, TNF induced expression of β6-integrin, TNF, and transforming growth factor beta. Of note, the bacterial wall component, MDP, induced mRNA levels of ETS-1, transforming growth factor beta, interleukin-13, SNAIL1, and β6-integrin in HT29 IEC monolayers and fistula CLPF by treatment for 24 hours.

CONCLUSIONS

TNF and MDP induce the expression of factors associated with epithelial-to-mesenchymal transition and invasion in IEC and fistula CLPF. Our findings indicate that TNF and MDP might synergize in the pathogenesis of CD-associated fistulae.

The role for dickkopf-homolog-1 in the pathogenesis of Crohn's disease-associated fistulae

Background

One of the most challenging conditions in Crohn’s disease (CD) patients is the treatment of perianal fistulae. We have recently shown that epithelial-to-mesenchymal transition (EMT) plays a crucial role during CD-fistulae development. Dickkopf-homolog 1 (DKK-1) is known to play a key role during EMT. Here, we investigated a role for DKK-1 in the pathogenesis of CD-associated fistulae.

Methods

Dkk-1 protein expression in CD-fistula specimens were investigated by immunohistochemistry. Colonic lamina propria fibroblasts (CLPF) were obtained from either non-IBD control patients or patients with fistulizing CD. HT-29 intestinal epithelial cells (IEC) were either grown as monolayers or spheroids. Cells were treated with either TNF-α, TGF-β or IL-13. Knock-down of DKK-1 or β-Catenin was induced in HT-29-IEC by siRNA technique. mRNA expression was determined by real-time-PCR.

Results

Dkk-1 protein was specifically expressed in transitional cells lining the fistula tracts. TGF-β induced DKK-1 mRNA expression in HT-29-IEC, but decreased it in fistula CLPF. On a functional level, DKK-1 knock-down prevented TGF-β-induced IL-13 mRNA expression in HT-29-IEC. Further, loss of β-Catenin was accompanied by reduced levels of DKK-1 and, again, IL-13 in IEC in response to TGF-β. In turn, treatment of HT-29-IEC as well as fistula CLPF with IL-13 resulted in decreased levels of DKK-1 mRNA. Treatment with TNF-α or the bacterial wall component, muramyl-dipeptide, decreased DKK-1 mRNA levels in HT-29-IEC, but enhanced it in fistula CLPF.

Discussion

We demonstrate that DKK-1 is strongly expressed in cells lining the CD-fistula tracts and regulates factors involved in EMT initiation. These data provide evidence for a role of DKK-1 in the pathogenesis of CD-associated perianal fistulae.

Sensitivity and specificity of magnetic resonance enterography in the clinical management of fistulizing Crohn's disease

BACKGROUND

High diagnostic accuracy is reported for magnetic resonance enterography (MRE) in Crohn's disease (CD), but few studies have evaluated its role in abdominal fistulae. The primary aim of this study was to assess the reliability of MRE in the identification of internal fistulae in CD.

METHODS

One hundred and eighty-six patients with moderate CD (CD Activity Index : 250-400) were prospectively selected from the inflammatory bowel disease clinic of Parma University Hospital. Eligible patients had already undergone nutritional screening, pancolonoscopy, and computed tomography enterography (CTE) in the month before enrollment. MRE was performed according to the study protocol. Additional fluoroscopic contrast-enhanced studies or surgical evaluation were used for discordance between CTE and MRE results. A consensus committee resolved equivocal findings. Surgical findings and/or fluoroscopic contrast-enhanced studies together with the clinical data were considered the composite "reference standard" to which the results of MRE were compared.

RESULTS

MRE identified 22 internal fistulae in 21 patients (11%), of whom 4 (19%) also had perianal fistulae and found 7 abscesses (33%). Forty-one (22%) additional patients with perianal fistulae were identified. Thirteen patients (57%) with internal fistulae required enteral nutrition support. No statistically significant differences were found between MRE and CTE in fistula detection. There was also no significant difference between MRE and the composite diagnosis in those who underwent surgery (n = 8) and/or contrast-enhanced studies (n = 7).

CONCLUSIONS

CTE and MRE accurately detect internal fistulae in CD. MRE is preferable because it avoids radiation. Reliable identification of internal fistulae by MRE should permit earlier and improved treatment.

Surgical management of Crohn's disease

Although medical management can control symptoms in a recurring incurable disease, such as Crohn's disease, surgical management is reserved for disease complications or those problems refractory to medical management. In this article, we cover general principles for the surgical management of Crohn's disease, ranging from skin tags, abscesses, fistulae, and stenoses to small bowel and extraintestinal disease.

Small intestine contrast ultrasonography (SICUS) for the detection of small bowel complications in crohn's disease: a prospective comparative study versus intraoperative findings

BACKGROUND

In Crohn's disease (CD) patients, small intestine contrast ultrasonography (SICUS) accurately assesses small bowel lesions. Its diagnostic role is not known in the assessment of intraabdominal CD complications. The aim was to assess the value of SICUS to detect intestinal complications in patients with CD.

METHODS

Forty-nine CD patients (21 female, mean age 37.7 years; range 12-78 years) underwent resective bowel surgery and were included in this study. The accuracy of SICUS to preoperatively detect number, site, and length of strictures, fistulas, and abscesses was compared with surgical and pathological findings by kappa statistics.

RESULTS

SICUS identified at least one stricture in 39/40 and excluded it in 9/9 (97.5% sensitivity, 100% specificity, k = 0.93); two or more strictures in 9/12 (75% sensitivity, 100% specificity, k = 0.78). The agreement by k-statistics between SICUS and surgery in identifying proximal and distal small intestine site of stricture was 1 and 0.92, respectively. The extension of strictures was 6.8 ± 5.4 cm at surgery, 6.6 ± 5.4 cm at SICUS (NS). Fistulas were correctly identified in 27/28 patients and excluded in 19/21 patients (96% sensitivity, 90.5% specificity, k = 0.88). Intraabdominal abscesses were correctly detected in 10/10 patients and excluded in 37/39 patients (100% sensitivity, 95% specificity, k = 0.89).

CONCLUSIONS

SICUS is an accurate method for the detection of small intestinal complications in CD. Noninvasive SICUS is valuable as a primary investigative method for evaluating and planning proper treatment in patients with severe CD of the small bowel.

Diffusion-weighted MRI: role in detecting abdominopelvic internal fistulas and sinus tracts

PURPOSE

To retrospectively determine the incremental value of diffusion-weighted MR-imaging (DW-MRI) to T2-weighted (T2w) images in diagnosis of internal fistulas (IFs) and sinus tracts (STs).

MATERIALS AND METHODS

Fourteen patients with 25 IFs and STs arising from the small bowel (20), colon (4) and biliary tract (1) were included. Two independent observers reviewed T2w images, T2w+DW-MRI images and T2w+contrast enhanced T1-weighted (CE T1w) images at three sessions to detect IF/ST based on a confidence scale of five. Sensitivity and confidence score of each session was compared.

RESULTS

10/25 (40%) and 9/25 (36%) IFs and STs were detected on T2w images by observer 1 and 2, respectively. Both observers detected 19/25 (76%) and 24/25(96%) IFs and STs on T2w+DW-MRI and T2w+CE T1w images, respectively. Detection rate and confidence score improved significantly by combining T2w images with DW-MRI or CE T1w images (reader 1 + 2: P ≤ 0.01). There was no significant difference between the IF/ST detection rate of T2w+DW-MRI and T2w+CE T1 image combinations. Confidence scores with T2w+CE T1w images were significantly greater than DW-MRI+T2w images (reader 1:P = 0.01; reader 2: P = 0.03).

CONCLUSION

DW-MRI showed additional value to T2w imaging for diagnosis of IF and ST. DW-MRI can be a useful adjunct, especially for patients with renal failure.

Potential role for SNAIL family transcription factors in the etiology of Crohn's disease-associated fistulae

BACKGROUND

Fistulae represent an important clinical complication of Crohn's disease (CD). The fistula tracts are covered by flat, myofibroblast-like cells with an epithelial origin (transitional cells, TC). We recently demonstrated a role of epithelial mesenchymal transition (EMT) in the pathogenesis of CD-associated fistulae. EMT is associated with an increased migratory and invasive potential of epithelial cells in different tissues. Here we investigated whether cytokines or growth factors as well as EMT-associated SNAIL family transcription factors are expressed in CD fistulae.

METHODS

By immunohistochemistry we analyzed seven perianal fistulae from seven CD and two perianal fistulae from two non-inflammatory bowel disease (IBD) control patients. Hematoxylin and eosin staining or immunohistochemistry for the expression of tumor necrosis factor (TNF), TNF-receptor I (TNF-RI), SNAIL1, SLUG, fibroblast growth factors (FGF) 1, 2, 4, 7, epidermal growth factor (EGF), and TWIST were performed using standard techniques.

RESULTS

Immunohistochemical staining of surgical specimens from CD patients revealed a strong expression of TNF and TNF-RI in and around fistula tracts. While SNAIL1 was also heavily expressed in the nuclei of TC, indicative of transcriptionally active protein, SLUG, FGF-1, and FGF-2 were detected rather in the fibrotic periphery of CD fistulae than in TC. In contrast, we did not detect considerable protein staining for FGF-4 and FGF-7 nor of EGF or the transcription factor, TWIST.

CONCLUSIONS

Our data demonstrate that SNAIL1 and TNF are strongly expressed in TC of CD-associated fistulae. These observations support our previous data and indicate the onset of EMT-associated events in the pathogenesis of CD fistulae.

Crohn's disease: a surgeon's perspective

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.

Intra-abdominal fistulas in surgically treated Crohn's disease patients

BACKGROUND

Intra-abdominal fistulas occur in one-third of patients with Crohn's disease (CD). Although they are common, these fistulas may pose difficult problems for the surgeon. We assessed the clinical presentation of intra-abdominal fistulas in patients with CD and compared the clinicopathologic characteristics of CD with and without fistulas.

METHODS

We analyzed consecutive laparotomy cases for 254 patients with CD between 1991 and 2008. Clinicopathologic data were abstracted from patient charts and a prospectively maintained database. Patient variables with and without fistulas were analyzed using the Fisher's exact test, chi-square test, and Student's t test.

RESULTS

A total of 93 surgical procedures were performed on 83 patients (32.7%) who had at least one intra-abdominal fistula, revealing a total of 122 fistulas. Enteroenteric fistulas were the most common (30.3%), followed by enterocutaneous (23%), enterosigmoid (19.7%), enterocolonic (9.7%), and enterovesical (9.7%). Most cases (95.7%) underwent intestinal resection, with primary anastomosis in 77 of the cases (82.8%). There was no mortality, although 15 (16.1%) patients experienced postoperative complications. In the comparison of 270 cases with and without fistulas, cases with fistulas tended to have more frequent surgeries for perianal fistulas or abscesses (P = 0.001), more frequent intra-abdominal abscesses on CT (P = 0.044), and a higher incidence of combined small bowel and colonic disease (P < 0.001).

CONCLUSIONS

The incidence and clinical features of fistulas were similar to those reported in previous studies of western patients. We identified that patients with CD and fistulas have more frequent other CD-related sepsis.

Trends in surgery for Crohn's disease in the era of infliximab

OBJECTIVE

To examine the use of surgical procedures for Crohn's disease since the introduction of infliximab.

SUMMARY BACKGROUND DATA

Prior studies have shown that the overall rate of surgery for Crohn's disease has not changed significantly since the introduction of infliximab, an immunomodulator considered particularly effective in treating Crohn's fistulas. How infliximab has affected individual rates of specific types of procedures, particularly surgery for intestinal fistulas, is unknown.

METHODS

We used the Nationwide Inpatient Sample to identify all hospital admissions for Crohn's disease for each year from 1993 through 2004. Cases of Crohn's disease and relevant surgical interventions were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Using US Census data to establish population denominators, trends in population-based rates of use of these procedures were examined over time. Trends were tested for significance with Spearman rank correlation tests.

RESULTS

From 1993 to 2004, there was no statistically significant change in population-based rates of small bowel and right colon resection, while rates of left colon resection, other colon resection, and rectal resection declined moderately. However, rates of surgical repair of fistulas of the small intestine, the most commonly performed fistula operation, increased by 60%, from 1.5 per 1,000,000 in 1993 to 2.4 per 1,000,000 in 2004 (P = 0.04).

CONCLUSIONS

During the period of adoption of infliximab as a novel treatment for Crohn's disease, overall rates of bowel resections have either remained relatively stable or decreased moderately, while rates of small bowel fistula repair have increased significantly. These findings call into question the effectiveness of infliximab in preventing the need for surgery for Crohn's disease at the population level.