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克罗恩病(Crohn’s disease,CD)往往会导致肛周局部的病变,常见的肛周克罗恩病(perianal Crohn’s disease,PCD)可表现为皮赘、痔、肛裂、溃疡、肛瘘、直肠阴道瘘、肛周脓肿、肛管直肠狭窄及恶性肿瘤。对于这些CD并发疾病的治疗应根据病人个体情况、医生的经验和判断,选择最恰当的治疗方式。大部分手术治疗应在避免有直肠炎症的情况下进行,将肛门失禁的风险最小化,同时避免直肠切除,提高病人的生活质量。     

Anal carcinoma in patients with Crohn''s disease

Three patients with Crohn's disease and carcinoma of the anus are reported and compared to a group of patients with anal cancer and no inflammatory bowel disease. The three patients with Crohn's disease were relatively young women with significant perianal disease. There were two squamous cell lesions and one cloacogenic tumor in this group. The relative incidence of anal cancer as a proportion of all colorectal cancer, in patients with Crohn's disease (14%) was found to be significantly higher than the incidence of anal cancer in patients without inflammatory bowel disease (1.4%). Possible reasons for the increased incidence of anal cancer in Crohn's disease mentioned were: an overall increase in malignancies in inflammatory bowel disease, the high incidence of perianal disease, and the chronic long-standing perianal inflammation present. All patients with Crohn's disease, especially if they have active perianal disease, should be observed for the occurrence of anal cancer.     

Crohn's disease: bowel resection to protect the proctium in severe perianal disease?

Patients with anal Crohn's disease generally have a bad prognosis. Up to 50% end up with an anus praeter or proctectomy. Many of these young people develop psychological and social problems causing them to become invalids. Local surgery and conservative therapy in such aggressive cases of Crohn's disease presenting with recurring perianal fistulae and abscesses are often unsuccessful; the destruction of the proctium continues. The purpose of our study was to look at the outcome of our patients with regard to these aspects. We included all 56 patients suffering from Crohn's disease treated at our clinic from 1984 until 1991 in a retrospective study and focused on the 13 patients with anal manifestation. The mean follow-up was 15.8 years (3-28 years). Often there was no improvement of perianal disease without resection of the involved bowel, especially in cases where both the colon and the rectum were affected. Anal destruction went on. Seven of the 13 patients suffering from anal complications finally received an anus praeter. An previous bowel-resection or the construction of a temporary anus praeter seem to be necessary to protect the proctium irrespective of abdominal symptoms in patients with recurrent severe perianal Crohn's disease.     

Treatment of perianal Crohn's disease

Perianal Crohn's disease (PACD) is defined as the presence of persistent lesions in the anal canal and perianal region in patients with Crohn's disease. The relative incidence of PACD in Crohn's disease patients ranges from 15 to 80% in the literature, depending on the accuracy of the clinical investigations and the clinical importance attributed to the lesions in the various study populations. The incidence is significantly higher if the intestinal disease is located in the colon-rectum rather than in the small bowel. We reviewed our experience in 105 patients with PACD, 32 of whom presenting rectal localisation of the primary disease. We observed 2 stenoses, 3 perirectal abscesses, 3 rectal ulcerations, 5 skin tags, 10 fissures and 77 fistulas. Two dilatations under narcosis, 2 intrarectal drainages of abscesses, 19 fistulotomies, 7 partial fistulotomies and insertion of loose setons, 47 loose setons and 4 anoperineal diversions were performed. The remaining patients received medical and topical treatments. After a median follow-up of 30 months, 90 patients (86%) showed a good response with improvement in functional scores, while 15 (14%) showed no improvement or a worsening requiring proctectomy in 13 cases. All patients submitted to proctectomy had rectal localization of the disease.     

Selective surgical management of Crohn's disease of the anus

To establish specific indications for the surgical treatment of perianal Crohn's disease, the authors report their experience with 102 patients (45%) with these lesions in a series of 225 patients with small- and large-bowel Crohn's disease. Ulcerations or fissures were present in 50%, abscesses developed in 32% and fistulas in 53%. More than one type of lesion was present in 59%. One of six patients had no symptoms, in one of five the lesion was etiologically independent of Crohn's disease and one of four patients did not require surgical intervention. Severe pain indicated an abscess that required drainage, and 57% of patients who underwent drainage alone or with an added seton later required fistulotomy to become symptom-free. Primary fistulotomy for abscess achieved complete healing in 71% of cases and fistulotomy also healed in 60% of chronic fistulas for a combined fistulotomy healing rate of 63% when anal Crohn's disease was present and 68% in all patients with Crohn's disease. Anal dilatations with bougies were effective in short stenoses which were present in 7% of cases. Twelve percent of patients required excision of the rectum to be relieved of their symptoms.     

Anovaginal and rectovaginal fistula in patients with Crohn's disease.

Between 1971 and 1991, details of 67 women with perianal Crohn's disease were recorded prospectively using the Cardiff classification. Two groups were identified according to the presence (n = 29) or absence (n = 38) of anorectal Crohn's fistula involving the vagina. Patients in both groups were of a similar age and had had Crohn's disease for a similar period before diagnosis of perianal involvement. The incidence of associated perianal lesions, superficial ulcers, cavitating ulcers, other fistulas and strictures was not significantly different between the two groups. A greater proportion of patients with anorectal-vaginal fistulation (n = 15) had distal intestinal Crohn's disease (rectal or contiguous colorectal) compared with women with no vaginal fistulation (n = 14). A range of therapies was used to manage women with perianal Crohn's disease, from local surgery to a defunctioning stoma and/or proctectomy. Only 13 of 38 women with perianal Crohn's disease but no vaginal fistula required a defunctioning stoma or proctectomy, whereas 18 of 29 with anorectal-vaginal fistulation underwent these procedures (P < 0.05). A vaginal fistula has a considerable adverse effect on the outcome of perianal Crohn's disease.     

Anal fissure in Crohn's disease

There is little information on the natural history of anal fissure in Crohn's disease. The case notes of all new patients with Crohn's disease attending one hospital between 1977 and 1983 were reviewed: there were 61 patients with this diagnosis and an unhealed anal fissure as the only anal lesion. Of these 61 patients the fissure healed in 42 (69 per cent) during medical treatment of the intestinal disease. Ten patients (16 per cent) developed other anal lesions and in the remaining nine patients the fissure remained unhealed at the time of rectal excision (six) or last out-patient attendance (three). Activity of the fissure did not reflect disease activity elsewhere in 11 cases in whom healing of the fissure occurred despite progressive intestinal disease subsequently requiring resection. This study validates the policy of conservative management of anal fissure in Crohn's disease with anal surgery (required in 9.8 per cent of patients in this series) being reserved for the development of other anal disease.     

Surgical treatment of anorectal complications in Crohn's disease

BACKGROUND: The purpose of our study was to elucidate features, surgical procedures, and long-term results in patients with anorectal complications of Crohn's disease. METHODS: Physical findings, surgical treatment, and long-term outcome were recorded prospectively for 224 patients who had anorectal complications of Crohn's disease between October 1984 and May 1999. RESULTS: Presenting complications included abscess (n = 36), fistula-in-ano (n = 51), rectovaginal fistula (n = 20), anal stenosis (n = 40), anal incontinence (n = 11), or a combination of features (n = 66). Twenty-four patients did not undergo surgical treatment; the remaining 200 patients underwent 284 procedures. Ultimately, 139 patients (62%) retained anorectal function; reasons for proctectomy in the remaining 85 patients included disease (n = 66), extensive fistular disease (n = 15), fecal incontinence (n = 2), and tight anal stenosis (n = 1). Patients with rectal disease had a significantly higher rate of proctectomy than patients with rectal sparing (77.6% vs. 13.6%, respectively, P<.0001). In the absence of rectal involvement, patients with multiple complications had a significantly higher rate of proctectomy than patients with single complications (23% vs. 10%, P<.05). CONCLUSIONS: A wide spectrum of surgical techniques is required for the management of the diverse anorectal complications of Crohn's disease. Complete healing and control of sepsis can be achieved in the majority of patients. Active rectal disease and multiple complications significantly increase the need for proctectomy.     

Anal and rectal cancer in Crohn's disease

Several epidemiological studies have been published regarding the risk of Crohn's disease‐ associated colorectal cancer. The findings are, however, contradictory and it has been particularly difficult to obtain indisputable information on the incidence of cancer limited to the rectum and the anus. During 1987–2000 rectal or anal cancer was diagnosed in 335 patients in Sweden (153 males, 182 females). In other words, approximately 3 Crohn patients per million inhabitants were diagnosed with rectal or anal cancer every year during that time period which is 1% of the total number of cases. At diagnosis of cancer 36% were aged below 50 years and 58% below 60 years. Corresponding figures for all cases of anal and rectal cancer were 5% and 18%, respectively. Present knowledge from the literature implies that there is an increased risk of rectal and anal cancer only in Crohn's disease patients with severe proctitis or severe chronic perianal disease. However, the rectal remnant must also be considered a risk factor. Multimodal treatment is similar to that in sporadic cancer but proctectomy and total or partial colectomy is added depending on the extent of the Crohn's disease. The outcome is the same as in sporadic cancer at a corresponding stage but the prognosis is often poor due to the advanced stage of cancer at diagnosis. We suggest that six high‐risk groups should be recommended annual surveillance after a duration of Crohn's disease of 15 years including extensive colitis, chronic severe anorectal disese, rectal remnant, strictures, bypassed segments and sclerosing cholangitis.     

Anorectal function in Crohn's disease.

Anorectal function was assessed in 63 patients with Crohn's disease and in 10 controls. Eleven patients with Crohn's disease (17%) were partially and three (5%) totally incontinent. The results of anal sphincter function studies of continent patients with Crohn's disease were similar to those of partially incontinent patients and controls. Incontinent patients had significantly lower maximal basal pressure (P less than 0.01) and significantly lower maximal squeeze pressure (P less than 0.05) as compared to controls. There was no significant difference in rectal capacity between continent, partially incontinent and totally incontinent patients and controls. There were significantly more patients with symptoms of anal incontinence in the group of patients with anal Crohn's disease as compared to the Crohn's group with normal anorectum (P less than 0.001). Risk factors for total anal incontinence in Crohn's disease were severe anorectal stenosis and previous surgery for anal abscesses. The most important reason for partial incontinence was diarrhoea. In conclusion, Crohn's disease without macroscopic lesions in the anorectum and without diarrhoea does not affect anorectal function.     

Risk of second primary colorectal cancer with particular reference to age at diagnosis

Objective:  Adenocarcinoma of the perineum is unusual. This series of nine patients highlights the challenges of management.
Results:  Six male and three female patients aged 29–85 years presented to a single unit, five were T4 and three were T3 tumours. Pain and swelling in the perineum and perianal tissues remote from the anal canal occurred in six patients whilst three patients had chronic perineal fistulae, two of whom had longstanding Crohn's disease. In eight patients a primary adenocarcinoma was identified. One patient with fistulating perineal Crohn's disease had multifocal mucinous adenocarcinoma without evidence of a gastrointestinal primary. Radical multimodality treatment including long course chemo-radiotherapy (CRT) and radical abdominoperineal resection was used in seven patients, four of whom required perineal reconstruction with myocutaneous flaps. Two patients had CRT without surgery, (one unresectable and one refused surgery). Negative resection margins were achieved in six out of seven patients. All seven patients undergoing resection were well palliated with relief of pain and currently four patients remain free of disease with only one patient developing further perineal disease remote from the surgical resection site.
Conclusion:  Perineal adenocarcinoma may be associated with an occult colorectal primary or chronic fistulae. Lower GI endoscopy and biopsies of nonhealing mucous producing fistulae should be undertaken to establish the diagnosis. Radical surgery often achieves local disease control.     

Surgery for Crohn's Disease: New Developments

Background/Aims: Crohn's disease is a chronic relapsing inflammatory bowel disease requiring surgery in a large number of patients. This review describes new developments in surgical techniques for treating Crohn's disease. Results: Single-incision laparoscopic surgery decreases abdominal wall trauma by reducing the number of abdominal incisions, possibly improving postoperative results in terms of pain and cosmetics. The resected specimen can be extracted through the single-incision site or the future stoma site. Another option is to use natural orifices for extraction (i.e. transcolonic/transanal), but actual benefits of these procedures have not yet been determined. In patients with extensive perianal disease or rectal involvement, transperineal completion proctectomy is often feasible, thereby avoiding relaparotomy. By using a close rectal intersphincteric resection, damage to the pelvic autonomic nerves is avoided. In addition, the risk of presacral abscess formation is reduced by leaving the mesorectal tissue behind. Conclusion: Minimally invasive surgery and associated techniques have become standard clinical practice in surgical treatment of patients with Crohn's disease. New developments aim at further reducing the hospital stay and morbidity, and improving the cosmetic outcomes.     

Anal and perianal lesions in Crohn's disease]

Crohn's disease is not a homogeneous clinical entity but may shows many clinical pictures during its period, prognosis and response to therapy. Anal and perianal localisations are frequently found; they can occur isolated, months or years in advance the disease, or can be concomitant with an ileal, colic or rectal involvement. There can be many kinds of lesions: simple, such as eczema or fissuration, complex, such as high rectal or rectovaginal fistulas. A rational classification of anal and perianal manifestations is suggested. Local medical therapy, is very effective in minor lesions, and has to be associated with systemic medical therapy particularly nowadays: the knowledge on phlogosis, biology and biotechnology revolution, have launched a new therapeutic era. Surgical therapy can be performed only in case of complex disease non responsive to medical therapy or when it is necessary to give a rest to anorectal tract. To perform a correct follow-up, considering unpredictability of lesions, a careful clinical evaluation and an intensive surveying plan associated with objective evaluation parameters are suggested.     

Risk of second primary colorectal cancer with particular reference to age at diagnosis

Objective:  Adenocarcinoma of the perineum is unusual. This series of nine patients highlights the challenges of management.
Method:  Six male and three female patients aged 29–85 years presented to a single unit, five were T4 and three were T3 tumours.
Results:  Pain and swelling in the perineum and perianal tissues remote from the anal canal occurred in six patients whilst three patients had chronic perineal fistulae, two of whom had longstanding Crohn's disease. In eight patients a primary adenocarcinoma was identified. One patient with fistulating perineal Crohn's disease had multifocal mucinous adenocarcinoma without evidence of a gastrointestinal primary. Radical multimodality treatment including long course chemo-radiotherapy (CRT) and radical abdominoperineal resection was used in seven patients, four of whom required perineal reconstruction with myocutaneous flaps. Two patients had CRT without surgery (one unresectable and one refused surgery). Negative resection margins were achieved in six of seven patients. All seven patients undergoing resection were well palliated with relief of pain and currently four patients remain free of disease with only one patient developing further perineal disease remote from the surgical resection site.
Conclusion:  Perineal adenocarcinoma may be associated with an occult colorectal primary or chronic fistulae. Lower GI endoscopy and biopsies of non-healing mucous producing fistulae should be undertaken to establish the diagnosis. Radical surgery often achieves local disease control.     

Staged mucosal advancement flap for the treatment of complex anal fistulas: pretreatment with noncutting Setons and in case of recurrent multiple abscesses a diverting stoma

OBJECTIVE: To assess the efficacy of a staged strategy for the treatment of complex perianal fistula. METHODS: Between January 1999 and April 2003 all consecutive patients with complex perianal fistulas were treated according to a staged strategy. Fistula tracks originating from the middle third or upper part of the anal sphincter were included. Patients were examined for recurrent fistulas and complaints of incontinence and soiling. Initial treatment consisted of a noncutting seton with or without a diverting stoma. Definitive surgical treatment consisted of an advancement flap or fistulotomy. RESULTS: Thirty patients were included (median age; 42 years, range 22-68 years). Seven had Crohn's disease without signs of rectal and anal involvement other than the fistula. At a median follow up of 22 months (range 8-52 months) in 29 (97%) patients, the wounds had healed completely; 7 (22%) patients subsequently developed a recurrent fistula and minor soiling occurred in 7 (23%) patients. CONCLUSION: Initial treatment with a seton with and without a diverting stoma minimizing inflammatory activity at the fistula site before definitive surgical treatment gave good results in this difficult group of patients.     

Anal sphincter function and sphincter preserving surgery

This article reviews the methods of assessing anal sphincter function and the place of sphincter-saving surgery in patients seen in the Gatrointestinal Unit of the Birmingham General Hospital between 1976 and 1984. (The main parameters for assessing sphincter function are maximinal and pressure at rest, maximum squeeze pressure, length of the high pressure zone, electromyography and parameters of rectal sensation.) Poor functional results were observed for patients having restorative surgery for rectal cancer when there is evidence of extrarectal tumour infiltration. It has now become our policy to avoid primary resection and anastomosis for fixed rectal cancer and for cancer involving the side walls of the pelvis. We would also question the value of low sphincter-saving surgery in patients with manometric evidence of a weak anal sphincter. Assessment of rectal capacity has been of predictive value in selecting patients suitable for ileorectal anastomosis in Crohn's disease. Sphincter preserving surgery in ulcerative colitis by ileorectal anastomosis or ileoanal anastomosis with pouch is unpredictable and continence is often imperfect. Repair of a rectal prolapse alone by a posterior rectopexy restores continence to 70% of patients but if incontinence persists post anal repair is beneficial in approximately 50% of cases. Incontinence which does not improve with medical therapy can often be restored by surgical treatment. Post anal repair restores continence to approximately 70% of cases and sphincter reconstruction to 80%.     

Surgery for Crohn's colitis.

The majority of patients with Crohn's colitis eventually require surgical excision of the disease. The decision as to which operation to perform depends on the extent and site of disease, distensibility of the rectum, the presence of perianal disease, the age and attitude of the patients and their acceptance or otherwise of a stoma. Total proctocolectomy and ileostomy gave the best long-term results for Crohn's colitis in terms of recurrence rate. Abdominal colectomy and ileorectal anastomosis often restores young patients to good health without the risk of impaired sexual function from pelvic dissection and a permanent stoma is delayed and sometimes avoided. Segmental colonic resection should be considered for isolated short segment of Crohn's colitis but the optimal timing of such a procedure is not clear.     

Abrikossoff's tumour: report of a rare case in anal perianal region

The authors report a rare case of a 47-year old man suffered from Crohn's disease and depression with multiple prominent lesions in the anal and perianal region. The biopsy of these lesions showed the presence of Abrikossoff's tumour. This tumour is very rare in the anal region and usually the lesions are small (0.5-3 cm) and solitary. The authors report this case because they considered it an interesting case for the localization and the appearance of the lesions.     

克罗恩病外科治疗85例分析

目的总结分析肠道克罗恩病（CD）的外科治疗策略。方法对1980—2005年收治的85例CD病人资料进行回顾性分析。结果近年来CD病人呈增多趋势，术前确诊率为23．53％。肠梗阻（25．88％）、右下腹包块（回盲部肿物，10．59％）、盲肠癌（12．94％）、急性阑尾炎（4．71％）是术前误诊的几大主要原因。手术方式以右半结肠切除术（37．65％），小肠部分切除（21．18％）为主，内、外瘘及肛周CD行外科处理预后良好。结论手术仍是目前肠道CD的重要治疗手段；手术方式依病变部位和并发症类型不同而有差异，术式选择和规范化手术操作是亟待解决的问题。     

The application experience of Relief and Relief Advance in practice of the coloproctological patients treatment

The application efficacy of Relief and Relief Advance preparations, as pathogenetically directed remedies, was established, basing on the examination and treatment results of 129 patients with anorectal zone diseases (acute and chronic hemorrhoids, anal fissure, the perianal skin pruritus, nonspecific ulcerative colitis, Crohn's disease). For local conservative treatment it is expedient to apply the complex of various pharmacological forms of the preparation. Combined application of Relief and Relief Advance preparations endorectally and locally on the wound surface is indicated after performance of elective and urgent operative interventions for rectal and perianal region diseases.