RESULTS OF MULTIPLE STRICTUREPUSTIES IN DIFFUSE CROHN'S DISEASE OF THE SMALL BOWEL

With extensive small bowel strictures due to Crohn's disease, resectional surgery may lead to short bowel syndrome. Strictureplasty (SP) has emerged as a useful alternative for selected strictures. This study reviews the results of 42 patients with diffuse obstructive Crohn's disease of the small bowel in whom at least four SP were performed in each patient (median: 7; range: 4–15; total SP: 315). Twenty-three patients (55%) had had 1–5 previous small bowel resections. Co-existing perforative disease was present in four patients (10%). Synchronous resection of a separate segment of small bowel was performed in 22 patients (52%). There was no operative mortality. Enterocutaneous fistula and/or intra-abdominal abscess developed in three patients (7%) and only one of these needed operative intervention. The median follow-up was 3 years (range: 10 months to 7 years). After SP, all patients experienced relief from obstructive symptoms. The median weight gain was 3 kg (range: -1–21 kg) and more than half the patients were weaned off steroids. Symptomatic recurrence occurred in 10 patients (24%) and was due to strictures (N= 9) and/or perforative disease (N = 2) at new site(s) unrelated to previous SP. Rate of symptomatic restricture of the SP site was 1.6% and was associated with new strictures elsewhere in all cases. Thus, in selected cases, SP is a safe and effective treatment for diffuse Crohn's strictures.     

ANAL PATHOLOGY IN PATIENTS WITH CROHN'S DISEASE

Background: A distinctive feature of patients suffering from Crohn's disease is a predisposition to develop a variety of anal complications. The aetiology of such conditions is unclear, and the reported incidence of anal involvement in Crohn's disease varies party due to the various criteria used for classification. This study aims to review the management of patients with symptomatic anal pathology associated with Crohn's disease at St Vincent's Hospital, Melbourne. Methods : A database of 306 patients with Crohn's disease referred to the department between January 1978 and October 1994 was reviewed to identify those patients with symptomatic anal disease. The anal pathology was recorded and classified. Demographic data and the clinical and surgical history of the patient were recorded. Results : Of the 306 patients with Crohn's disease, 129 (42.4%) were identified as having symptomatic anal pathology. Patients were likely to present with anal symptoms after they had been diagnosed as having intestinal Crohn's disease (46.1%). The commonest presentations were perianal abscess (29.5%), anal fissure (27.6%), and low anal fistula (26.7%). A minority of patients presented with highkomplex anal fistulae (3.8%), or recto-vaginal fistulae (5.2%). Five per cent of patients had Crohn's disease localized to the anal area. The pattern of intestinal disease in the remaining patients was small bowel 21.1%. small bowel and colon 31.9%, and colon 43.0%. A total of 244 local anal surgical procedures were performed on these patients; the commonest of these were drainage of an abscess (38.5%), examination under anaesthetic (29.1%). and laying open of a low anal fistula (22.5%). Following surgical treatment, the recurrence rate for perianal abscesses was 13%, and for low anal fistulae 6%. Conclusions : The majority of patients with Crohn's disease who develop anal pathology have an excellent prognosis. A minority of patients develop complex anal fistulae and these remain a therapeutic challenge.     

Colorectal intervention as part of surgery for patients with gynaecological malignancy

OBJECTIVE: This study was conducted to determine the indications for and outcome of colorectal intervention in patients with advanced gynaecological malignancy. METHODS: Between January 1999 and June 2004, 27 gynaecological cancer patients underwent 36 colorectal intervention performed by general surgeons. The 36 operations were associated with 14 (39%) primary surgical procedures, 9 (25%) second-look laparotomies, and 13 (36%) procedures for recurrence or palliation. RESULTS: The mean age was 56 years (range 32-83 years). The majority of operations were performed in patients with ovarian (67%), endometrial (18%) and cervical (15%) malignancy. The primary indications for colorectal resection was tumour cytoreduction in 56% of the 36 operations. Other indications included repair of iatrogenic bowel injuries (n = 9, 25%), resection for multiple iatrogenic enterotomies (n = 4, 11%), and bowel obstruction (n = 3, 8%). The most frequently performed bowel operation was rectosigmoid resection with end-to-end anastomosis (n = 19, 53%). Colostomy was performed in 14% of the rectosigmoid resections at primary surgery. Small-bowel resection was required in 31% of the 36 operations. Postoperative complications included wound complications (14%), pulmonary infections (8%), cardiac complications (6%) and intra-abdominal abscess (6%). There was a single surgical mortality (3%). CONCLUSION: Colorectal intervention is frequently indicated during operations for advanced gynaecological malignancy, and they are associated with a significant rate of postoperative complications. Specialists operating on gynaecological malignancy should have the technical skills necessary to perform these procedures.     

Crohn disease: results of a series of 42 intestinal resections

Forty-two patients underwent a resection for acute or chronic complications of Crohn's disease during the years 1983-1987. The colon was involved in 38% (16 patients), the small bowel in 31% (13 patients) and the ileocaecal region in 31%. In small bowel disease, the indication for operation was either an intestinal obstruction or an internal abscess. In colonic locations, poor response to medical therapy was the indication for operation in 10 patients (63%), and an acute complication in the remaining cases. The operations performed were always "radical resections": 13 resections of small bowel, 13 ileocaecal resections, 7 ileocolectomies with ileosigmoidostomies, 6 ileocolectomies with ileorectostomies, 2 left side hemicolectomies with colorectostomies and one total coloproctectomy. There was no operative mortality. A post-operative complication occurred in two patients (4.8%). The recurrence rate was 12% after 30 months average follow up in the 34 patients with only one operation for Crohn's disease. There was no second recurrence in the 8 patients operated for a first recurrence. The factors affecting recurrence after resection were: a short pre-operative time interval since first clinical symptoms: 4.6 years versus 5.3 years without recurrence (p less than 0.01); the colonic location of the Crohn's disease (p less than 0.02). Colonic location rate of the disease was found to be higher in this study as compared to others. Since "radical resection" fails to cure all patients, surgery should be restricted to acute on chronic complications.     

Post-operative recurrence in Crohn's disease. Critical analysis of potential risk factors. An update

IntroductionCrohn's disease is associated with high rates of postoperative recurrence. At 10 years after surgery a high percentage of patients suffer recurrence (as many as 75% and above) and many of these (up to 45%) require re-intervention. The aim of the study was to identify, amongst the various “potential predictive factors”, those which today should be considered “real risk factors” for postoperative recurrence.MethodsA review of literature of the last 30 years was carried out. A medical literature search was conducted using Medline, Embase, Ovid Journals, Science Direct, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews. Potential risk factors related to the patient, disease, type of surgery and pharmacological treatment were analyzed.ResultsAccording to most Authors predictive factors, in addition to smoke, are also represented by an extent of disease superior to 100 cm and by absence of postoperative pharmacological treatment. Moreover, according to “the second European evidence-based Consensus on the diagnosis and the management of Crohn's disease: Special situations”, localization of disease in the colon, penetrative behavior of disease, extensive small bowel resection and prior intestinal surgery should also be considered predictive factors.ConclusionsThe high incidence of postoperative recurrence in Crohn's disease mandates a strict follow up (clinical, laboratory and instrumental monitoring). Identifying patients with increased risk would enable physicians to plan a surveillance program and to implement a rational therapeutic prophylaxis.     

Strategy for Surgical Management of Ileocolonic Anastomotic Recurrence in Crohn's Disease

After resection for ileocecal or ileocolonic Crohn's disease anastomotic recurrence is common, and many patients require further surgery. This study reviews our overall experience of surgery for ileocolonic anastomotic recurrence of Crohn's disease so we can propose a strategy for management. A series of 109 patients who underwent surgery for anastomotic recurrence after ileocecal or ileocolonic resection for Crohn's disease between 1984 and 1997 were reviewed. Ileocolonic recurrence was treated by strictureplasty in 39 patients and resection in 70 (with sutured end-to-end anastomosis, 48; stapled side-to-side anastomosis, 22). Stapled anastomosis has been frequently used between 1995 and 1997. Short recurrence was mainly treated by strictureplasty, and long or perforating disease was resected. Coexisting small bowel disease was more common in the patients having strictureplasty. Septic complications (leak/fistula/abscess) related to the ileocolonic procedure occurred in 1 of 39 patients (3%) after strictureplasty, in 6 of 48 (13%) after resection with sutured anastomosis, and in none of 22 after resection with stapled anastomosis. The median duration of follow-up was 90 months after strictureplasty, 105 months after resection with sutured anastomosis, and 22 months after resection with stapled anastomosis. Altogether 18 of 39 patients (46%) after strictureplasty, 22 of 48 (46%) after resection with sutured anastomosis, and none of 22 after resection with stapled anastomosis required further surgery for suture line recurrence. In conclusion, strictureplasty is useful for short ileocolonic recurrence in patients with multifocal small bowel disease or previous extensive resection. Stapled side-to-side anastomosis was associated with a low incidence of complications, and early recurrence was not observed, although the duration of follow-up was short.     

Incidence of pathogenic bacteria from mesenteric lymph nodes and ileal serosa during Crohn's disease surgery

Samples of ileal serosa and mesenteric lymph nodes have been harvested before antibiotic administration during 46 non-contaminated operations for Crohn's disease and compared with 43 operations for conditions other than Crohn's. Potentially pathogenic bacteria were isolated from the serosa in 12 (27 per cent) Crohn's patients, compared with 6 (15 per cent) controls (P = 0.04). Intestinal bacteria were recovered from mesenteric nodes in 15 (33 per cent) Crohn's patients compared with 2 (5 per cent) controls (P = 0.006). These findings suggest that bacteria leak from the small bowel lumen in a high proportion of Crohn's disease patients. This may explain the pathogenesis of abscess and fistula in this disorder as well as the high rate of sepsis following elective surgery even in the absence of macroscopic contamination.     

Laparoscopic surgery for lower gastrointestinal fistulas

Background: Increased experience and improved instrumentation have lead to a reduction in morbidity and a commensurate increase in the spectrum of laparoscopic indications. The purpose of this study was to assess the feasibility of laparoscopic surgery in patients with gastrointestinal fistulas. Methods: Between March 1993 and March 1995, patients with gastrointestinal fistulas who were laparoscopically treated were analyzed for age, gender, diagnosis, type of procedure, operative time, conversion rate, length of postoperative hospitalization, time until oral intake and return of bowel function, morbidity, and mortality. Results: Ten patients (five females; five males) with a mean age of 49.7 (range 20–86) years were preoperatively diagnosed as having the following fistulas: colocutaneous fistula due to diverticulitis (one), enterocolic fistula (two)—due to Crohn's ileocolitis (one) and due to diverticulitis (one)—pouchvaginal fistula after restorative proctocolectomy for familial adenomatous polyposis (two), colofallopian fistula due to diverticulitis (one), rectourethral fistula due to Crohn's disease (one), high transsphincteric fistula due to perianal Crohn's disease (one), enteroenteric fistula due to Crohn's disease (one), and colovesical fistula due to diverticulitis (one). Procedures performed consisted of sigmoidectomy with coloproctostomy (four), ileocolic resection (two), small-bowel resection with ileostomy (one), and diverting loop ileostomy (three). A complex jejunal enterotomy was noted in one (10%) patient. The mean operative time was 195 (range 75–360) min and mean postoperative hospital stay was 6.1 (range 3–12) days. Two additional cases were converted to open procedures for extensive disease (one) and adhesions (one). The patients started oral intake after a mean of 2.2 (range 1–5) days and bowel function returned after a mean of 3.4 (range 2–7) days. One patient required laparotomy on postoperative day 7 for a malrotated loop ileostomy. Conclusions: Laparoscopic colorectal surgery is feasible in patients with simple lower gastrointestinal fistulas. The morbidity rate of 10% and length of hospitalization of 6 days are similar to results after laparoscopic procedures for ``simpler'' colorectal pathology. However, the 30% conversion rate is higher, attesting to the challenging nature of these conditions.     

克罗恩病并发腹腔脓肿的临床特征与外科治疗

目的探讨克罗恩病(CD)合并腹腔脓肿的临床特征和外科治疗及预后。方法对2000-2005年间收治的142例CD患者其中合并腹腔脓肿的39例临床资料进行总结分析。结果本组CD患者合并腹腔脓肿的总发病率为27.5%,从发病到脓肿形成的时间范围为0-22年,平均5年。发病年龄(34.7±12.3)岁。24例(61.5%)患者既往有手术史;30例(76.9%)患者的脓肿发生在右侧腹,尤其是在吻合口附近(48.7%)。36例(92.3%)采取手术治疗,其中34例(34/36,94.4%)行手术引流加病变肠管切除,恢复良好。结论CD有较高的腹腔脓肿并发率,发病年龄多在35岁,将近50%发生在原吻合口;脓肿前的CD病程平均5年;手术方式以脓肿引流加病变肠管切除为主。     

Mesentery lymphoma in a patient with Crohn's disease: An extremely rare entity

INTRODUCTIONLymphoma is a rare complication of long-standing Crohn's disease. We report a rare case of a diffuse, B-cell non-Hodgkin's lymphoma of the mesentery in a patient receiving treatment for Crohn's disease.PRESENTATION OF CASEA 52 year-old patient presented with abdominal pain, anorexia and postprandial fullness. Abdominal examination revealed a firm mass, extending from the epigastrium to the right iliac fossa. CT scan showed a large intra-abdominal mass with air-fluid levels within, and soft tissue density along its walls, surrounded by distended bowel loops. The patient was scheduled for surgery due to clinical assumption of an intra-abdominal abscess. At laparotomy an ill-defined, lobulated mass with cystic areas was noted rising from the mesentery. Frozen section biopsy of the cystic mass revealed a non-Hodgkin follicle center B-cell lymphoma of the mesentery.DISCUSSIONTo the best of our knowledge, this is an extremely rare case of lymphoma development in the mesentery, in a patient receiving treatment for Crohn's disease. Although the development of abdominal lymphomas can be justified as a possible consequence of the chronic immune-modulating therapy, their location can lead to diagnostic pitfalls.CONCLUSIONAlthough mesentery has scarcely been presented as a potential site of occurrence of abdominal lymphomas in the process of treatment of inflammatory bowel diseases, this rare entity should be considered in the differential diagnosis of intra-abdominal lymphomas in patients with inflammatory bowel disease. In cases where imaging techniques do not provide definitive answers, surgical intervention can safely pose the accurate diagnosis.     

One-stage resection and primary anastomosis following acute obstruction of the left colon for cancer

The purpose of this study was to analyze the outcome in patients with acute obstruction of the left colon for cancer and treated by intraoperative decompression, on-table lavage, resection, and primary anastomosis. Between March 1992 and May 1998, 50 patients with acute obstruction of the left colon for cancer underwent surgery. Of these, 39 patients (25 men and 14 women; mean age, 65 years; range, 23-89) were treated with intraoperative decompression, on-table lavage, resection, and primary anastomosis. Six patients (15%) had fecal localized peritonitis. Left colectomies were performed in 16 patients (32%), partial colectomies in 19 patients (38%), and anterior resections in 4 patients (8%). The primary anastomosis was intraperitoneal in 29 patients (74%) and below the peritoneal reflection of the rectum in 10 (26%). The postoperative course was uneventful in 30 of the 39 cases. One patient (3%) died (within 30 days from surgery) from septic shock and multiple organ failure syndrome. Anastomotic leakage was observed in 2 patients (6%). An intra-abdominal abscess occurred in one case (3%). Other common complications included wound infections in 3 patients (8%). This experience suggests that intraoperative decompression, on-table lavage, resection, and primary anastomosis can be performed safely in selected patients with acute obstruction of the left colon for cancer than in those with an anastomosis in the nondiverted colon. Anastomosis below the peritoneal reflection is also not a contraindication.     

Long-term results of strictureplasty for ileocolonic anastomotic recurrence in Crohn’s Disease

This study examined the outcome of strictureplasty for recurrence at the ileocolonic anastomosis after resection (ileocolonic strictureplasty) in Crohn’s disease. The records of 42 patients who underwent ileocolonic strictureplasty between 1980 and 1997 were reviewed. The method of ileocolonic strictureplasty was Heineke-Mikulicz reconstruction for a short stricture (<-6 cm) in 41 patients and Finney reconstruction for a long stricture (20 cm) in one. Synchronous operations were performed for coexisting small bowel Crohn’s disease in 17 patients: strictureplasty in eight, resection in two, and both in seven. Postoperatively there were two intra-abdominal abscesses, which were treated conservatively. There were no deaths. All except two patients had complete relief of symptoms after operation. Most of the patients who had preoperative weight loss gained weight (median gain +2.6 kg). After a median follow-up of 99 months, 24 patients (57%) had a symptomatic recurrence. Three patients were successfully managed by medical treatment. The other 21 patients (50%) required surgery for recurrence (20 for recurrence at the previous ileocolonic strictureplasty site). At present, two patients are symptomatic and currently receiving corticosteroid therapy. All other patients have had no recurrent symptoms. None of the patients have developed short bowel syndrome or small bowel carcinoma. Strictureplasty is a safe and efficacious procedure for ileocolonic anastomotic recurrence in Crohn’s disease.     

Surgery for acute Crohn's colitis: Results and long term follow-up

Acute Crohn's disease of the colon requiring emergency surgery is uncommon, but may be increasing in frequency. Between 1954 and 1981, 215 patients had surgery for acute inflammatory bowel disease at St. Mark's Hospital, and of these 18 had acute Crohn's colitis. There was one postoperative death, and the remaining patients were followed up for an average of 8 years. Ten patients had toxic dilatation, two a toxic dilatation with free perforation, three had perforation without dilatation and in three surgery was required for an acute deterioration. Surgical treatment included proctocolectomy (one), colectomy and ileostomy (fourteen), colectomy and ileorectal anastomosis (two) and defunctioning ileostomy alone (one). Subsequent rectal excision was necessary in ten of sixteen patients. Acute colonic Crohn's disease requiring surgery is less likely than ulcerative colitis to be amenable to restorative surgery despite a policy of rectal conservation.     

Does perioperative biological therapy increase 30-day post-operative complication rates in inflammatory bowel disease patients undergoing intra-abdominal surgery? A systematic review

BackgroundBiopharmaceuticals revolutionised inflammatory bowel disease (IBD) treatment. However, it is postulated they compromise immunity, collagen production and angiogenesis resulting in infective post-operative complications and altered wound/anastomotic healing. Research has failed to agree on risks associated with perioperative biologics therefore it was anticipated that a systematic review may provide a consensus and contribute recommendations for clinical practice.MethodsA systematic review conducted as per PRISMA guidelines included a methodical search of PubMed, Google Scholar, EMBASE/Ovid and Cochrane Library using MeSH and/or keywords for papers published between 01/01/1998 and 04/02/2019.The population analysed included adult ulcerative colitis, Crohn's disease, Indeterminate Colitis or IBD unclassified patients. The intervention was intra-abdominal surgery in patients treated with biological therapy in the preceding 12 weeks compared to patients who had intra-abdominal surgery without biological therapy within the defined timeframe. The primary outcome was surgical site infection (SSI) with secondary outcomes including wound dehiscence, intra-abdominal sepsis/abscess, systemic infection and anastomotic breakdown within 30 days post-procedure. Papers were evaluated by two independent reviewers and those included were assessed for quality/bias using the Newcastle–Ottowa scale.Results2064 UC, Crohn's and IC patients were analysed across 8 included studies. Several studies' multivariate analyses demonstrated corticosteroids to be independent predictors of morbidity. There are no increased complications associated with anti-TNFα exposure while vedolizumab increased SSI and small bowel obstruction.ConclusionProspective studies and randomised control trials are required to clarify study outcomes and recommendations published to date. Presently, biologics should continue to be used and considered beneficial in this population.     

Preoperative Magnetic Resonance Enterography in Predicting Findings and Optimizing Surgical Approach in Crohn's Disease

Background

Many Crohn's disease patients require surgery. Intraoperative detection of new lesions may lead to change in planned surgery. This study aimed to determine whether magnetic resonance enterography can optimize surgical planning and guide decision making in Crohn's disease.

Methods

Seventy-five patients with complicated Crohn's disease were enrolled and underwent preoperative magnetic resonance enterography. Analysis included imaging accuracy and change in surgical strategy due to discordance with imaging findings.

Results

Surgery was performed laparoscopically in 39/75 patients (52 %), with conversion to open surgery required in six (15 %). Concordance between observers was excellent (kappa value >0.8). Magnetic resonance enterography accuracy for stenosis, abscess, and fistula were all above 85 % in per-patient analysis. In 68/75 cases (90.7 %) surgery was correctly predicted. Conversely, in 7/75 cases (three false-positives and four false-negatives) surgical strategy (type of resection or strictureplasty, n?=?5) and/or surgical approach (conversion from laparoscopy to open surgery, n?=?2) changed due to discordance with magnetic resonance enterography findings.

Conclusion

Surgical strategy and approach are correctly predicted by magnetic resonance enterography in the majority of patients with complicated Crohn's disease.     

Segmental versus total colectomy for large bowel Crohn's disease

Reports of the long-term results of excisional surgery for Crohn's disease restricted to the large intestine have revealed apparently conflicting data. Recurrent enteritis after colectomy and ileotomy varies from 3% to 46%. Variations in patient selection, differences in pathologic criteria and criteria for defining recurrences, and length, completeness, and accuracy of the follow-up may well explain such differences in the literature. Certainly, the extent of the operative procedure could influence recurrence rates. A retrospective review was undertaken to determine whether segmental colon resection was ever justified in patients with Crohn's disease clinically confined to the colon.     

Clinical outcome and factors predictive of recurrence after enterocutaneous fistula surgery

OBJECTIVE: Recent experience with surgery for enterocutaneous fistulae (ECF) at a specialist colorectal unit is reviewed to define factors relating to a successful surgical outcome. SUMMARY BACKGROUND DATA: ECF cause significant morbidity and mortality and need experienced surgical management. Previous publications have concentrated on mortality resulting from fistulae, while factors affecting recurrence have not previously been a focus of analysis. METHODS: Records were reviewed of patients who had ECF surgery (1994-2001). Management strategy involved early drainage of sepsis and nutritional support prior to elective ECF repair, with selective defunctioning proximal stoma formation. RESULTS: A total of 205 patients were available (89 males, 43%; median age, 51 years; range, 16-86) years). ECF were related to Crohn's disease in 95, ulcerative colitis in 18, diverticular disease in 17, carcinoma in 25 (16 after radiotherapy), mesh ventral hernia repair in 21, and other causes in 29. Forty-one (20%) had undergone attempted fistula repair at other institutions. Initial management included CT-guided drainage of an intra-abdominal abscess in 23 patients, and total parenteral nutrition in 74 (36%). A total of 203 patients had definitive ECF repair. Forty-four had oversewing or wedge resection of the fistula, and 159 had resection and reanastomosis of the involved small bowel segment or ileocolic anastomosis. Ninety-day operative mortality was 3.5%. A total of 42 (20.5%) patients developed ECF recurrence within 3 months. Multivariate analysis demonstrated that recurrence was more likely after oversewing (36%) than resection (16%, P = 0.006). CONCLUSIONS: A strategy of drainage of acute sepsis, maintenance of nutritional support prior to surgery, and selective use of PS allows for primary closure in 80% of complicated ECF. Resection should be performed when feasible.     

Strictureplasty in Crohn’s Disease: Short and Long-Term Follow-Up

Strictureplasty for obstructive Crohn’s disease is still controversial because lesions are left in place and the suture is performed on a diseased bowel. Many surgeons prefer to perform bowel resection, hoping for fewer complications and a lower recurrence rate. In this paper, the authors report their strictureplasty experience. They performed a systematic retrospective review of the patients suffering from Crohn’s disease who underwent strictureplasties during a 10-year period in the abdominal surgery department of the University Hospital of Liège Sart Tilman, and studied the short-and long-term clinical results of 68 strictureplasties performed in 18 patients. Median follow-up was 63 months (range 12 to 144). Mortality was 0% and septic morbidity was 11% (one wound abscess and one leakage). Among the 16 patients available for the latest follow-up, symptomatic stenotic recurrence had to be medically treated in hospital for 4 patients (25%) with a recurrence delay range of 19 to 49 months. Stenosis recurrence needed re-intervention in one patient 48 months after surgery: stenosis occurred at a distance from the corrected site. These results confirmed that strictureplasty is a safe and efficient procedure in selected patients undergoing surgery for obstructive Crohn’s disease.     

Spontaneous free perforation and perforated abscess in 30 patients with Crohn''s disease.

Spontaneous free perforation is an uncommon event in the natural history of Crohn's disease. It occurred in 21 of 1415 patients (1.5%) admitted with Crohn's disease to The Mount Sinai Hospital between 1960 and 1983. The mean duration from onset of Crohn's disease to occurrence of perforation was 3.3 years. Ten patients had small bowel perforation, ten patients had large bowel perforation, and one patient had simultaneous perforation of both ileum and cecum. The incidence of perforation in disease segments of small bowel was 1.0% (jejunum 6.0%, ileum 0.7%), and in the colon, 1.3%. Besides the 21 patients with spontaneous free perforation, an additional nine patients had spontaneous free rupture of an abscess into the peritoneal cavity. The mean duration from onset of Crohn's disease to rupture of abscess was 8.5 years. All 30 patients had surgery within 24 hours of perforation or rupture. All 21 patients with spontaneous free perforations survived, as did all but one of the nine patients with perforated abscess. The cornerstone of the treatment of ileocolonic lesions perforating into the general peritoneal cavity is proximal diversion with delayed reconstruction of intestinal continuity whenever possible. With perforation of the small bowel, primary reanastomosis is possible in selected patients.     

A 10-year review of surgery for desmoid disease associated with familial adenomatous polyposis

BACKGROUND: Desmoid tumours affect 10-25 per cent of patients with familial adenomatous polyposis and represent a major cause of morbidity and mortality. Surgery for intra-abdominal desmoids has traditionally been used as a last resort or to manage obstructive complications. The aim was to review 10 years of desmoid surgery in patients with familial adenomatous polyposis from a single centre. METHODS: Patients who had surgery for desmoid disease between 1994 and 2004 were identified from the Polyposis Registry database and their hospital notes reviewed. RESULTS: Twenty patients had surgery to remove 32 desmoid tumours (16 intra-abdominal, 12 abdominal wall, four extra-abdominal). Complete clearance was achieved in 19 tumours and, of these, clinically significant recurrence occurred in eight. There was no difference in recurrence rates for site or sex. There was no operative mortality. Intra-abdominal desmoid resection was associated with a mean resection of 45.55 (range 10-200) cm of small bowel. One patient required long-term parenteral feeding. Median follow-up was 5 (range 0.6-10) years. During this period, one patient died (metastatic duodenal cancer); there was no mortality from desmoid disease. CONCLUSION: Surgery for intra-abdominal desmoids in selected patients is less hazardous than previously reported. Surgery for abdominal wall and extra-abdominal tumours is safe. However, disease recurrence remains a major problem.