Anal complications in Crohn's disease

Anal fissures, fistulas, and abscesses occurred as complications in 22 per cent of our population of 1,098 patients with Crohn's disease. Crohn's colitis was much more frequently associated with an anal lesion than Crohn's disease of the small bowel (52 per cent vs. 14 per cent). When an anal lesion is the manifesting sign, Crohn's disease will soon develop elsewhere in the intestine. Since these lesions frequently herald the onset of intestinal Crohn's disease, the physician must always be aware of the possibility of inflammatory bowel disease when dealing with suspicions anal lesions. Read at the Meeting of the American Society of Colon and Rectal Surgeons, Hollywood Florida, May 11 to 16, 1980.     

Anal Crohn's disease with carcinomain Situ

Summary A 36-year-old female with a six-year history of Crohn's disease of the anus and colon was found to havein situ cloacogenic carcinoma of the anus after having undergone total proctocolectomy for massive bleeding. This case further supports the association between Crohn's disease of the gastrointestinal tract and its potential for malignant degeneration.     

Crohn's disease. Clinical manifestations

Two hundred and fourteen patients with Crohn's disease (CD) consecutively admitted during a 5-year period were observed for a mean of 9 years (range, 0-35 years). Sixty-five per cent had their initial symptoms between 10 and 30 years of age and 9.2% after the age of 50 years. The CD diagnosis was delayed for more than 10 years in 8% (mean, 4.5; range, 0-31 years). Large-bowel involvement was seen in 82.5% and was the only localization of the disease in a fourth of the patients. Recurrent abdominal pain occurred in two-thirds of patients with ileal or ileocolic disease. Acute abdominal pain was the cause of laparotomy in 14% of the patients with ileocolic CD. Diarrhea and rectal bleeding occurred significantly more often in colonic CD, whereas fistula complicated ileocolic disease more often than isolated involvement of small or large bowel. Associated extraintestinal diseases were seen in 117 patients (55%), most frequently related to colonic involvement (joint disease, 21%; eye, 12%, skin, 8%). Of 26 patients (12%) with liver pathology, 10 patients had amyloid deposits. Amyloidosis was diagnosed in altogether 12 patients (6%).     

Hospitalisations and surgery in Crohn's disease

Hospitalisation and surgery are considered to be markers of more severe disease in Crohn's disease. These are costly events and limiting these costs has emerged as one rationale for the cost of expensive biologic therapies. The authors sought to review the most recent international literature to estimate current hospitalisation and surgery rates for Crohn's disease and place them in the historical context of where they have been, whether they have changed over time, and to compare these rates across different jurisdictions. It is in this context that the authors could set the stage for interpreting some of the early data and studies that will be forthcoming on rates of hospitalisation and surgery in an era of more aggressive biologic therapy. The most recent data from Canada, the United Kingdom and Hungary all suggest that surgical rates were falling prior to the advent of biologic therapy, and continue to fall during this treatment era. The impact of biologic therapy on surgical rates will have to be analysed in the context of evolving reductions in developed regions before biologic therapy was even introduced. Whether more aggressive medical therapy will decrease the requirement for surgery over long periods of time remains to be proven.     

Laparoscopic surgery in Crohn's disease

In a prospective study the feasibility and safety of laparoscopic-assisted ileocaecal resection for Crohn's disease was studied and compared with 16 patients who had open ileocaecal resection, and the value of laparoscopic stoma surgery was assessed. From January to November 1995 laparoscopic-assisted ileocaecal resection for Crohn's disease was undertaken in 7 patients, laparoscopic-assisted stoma formation in 10 patients. In 1 patient laparoscopic ileocaecal resection was converted to open surgery due to an unrecognised ileocolic fistula. Operating time in laparoscopic-assisted ileocaecal resections was longer than in open ileocaecal resection (150 vs. 127 min, P=0.7). Blood loss (386 vs. 445 ml, P=0.7), first bowel movement (3.5 vs. 4.9 postoperative days, P=0.07) and postoperative time to discharge (5.2 vs. 9.9 days, P<0.01) in patients who had a laparoscopic-assisted ileocaecal resection were less than in patients who had open surgery. In all 10 patients laparoscopic formation of a stoma was possible. Operating time was 62 min. Oral solids were restored on the 1.5 postoperative day. Mean postoperative stay was 8.8 days, prolonged due to time needed for stoma-care training. These preliminary results indicate that laparoscopic-assisted ileocaecal resection and stoma surgery for Crohn's disease are feasible and safe. Both procedures are characterised by rapid recovery and superior cosmetic results.     

Clinical profile and predictors of disease behavior and surgery in Indian patients with Crohn's disease

Background

Recent years have seen the emergence of Crohn's disease (CD) in India and the predictors of disease behavior and surgery in these patients are not known.

Methods

The demographic and clinical profiles of patients diagnosed to have CD from January 1995 to December 2008 were analyzed retrospectively and associations with disease behavior and surgery were determined using multivariate analysis.

Results

Two hundred and twenty-three patients (age 35?±?14.7 years, males 57.9 %) were included. Extraintestinal manifestations were noted in 27.4 % patients. There was a median delay of 24 months to diagnosis; 66 (29.6 %) patients received antitubercular therapy prior to diagnosis. The most common site of involvement was ileocolonic (40.4 %), and the most common disease behavior was nonstricturing and nonpenetrating (57.8 %). The disease was moderate to severe in 79 %. Around 40 % patients had a relapsing course of illness. Seventy-three patients (32.7 %) had at least one surgical intervention. Independent associations with aggressive disease behavior included the presence of small bowel disease and longer duration of illness. Predictors of surgical intervention were male sex, small bowel disease, perianal disease, and aggressive disease behavior.

Conclusion

Diagnosis of CD is still delayed in India. Longer duration of illness predicted aggressive disease behavior. Surgery was performed more often in males with aggressive disease involving the small bowel and perianal area.     

Anal fistulas in Crohn's disease: Incidence and outcome of surgical treatment

The incidence and prognosis of anal fistulas were investigated in a prospective study comprising 136 patients operated on for Crohn's disease. The incidence of anal fistulas was 27 of 136 (20%), in patients with classical disease 12 of 68 (18%), and in those with Crohn's colitis 15 of 68 (22%). A fistula preceded the intestinal manifestation of the disease in 6 patients. At the time of diagnosis of Crohn's disease anal fistulas were observed in 19 cases, including 3 of the 6 with early onset which had resisted treatment and remained active. Five patients developed anal lesions during the course of the disease, all but 2 in temporal relationship to an intestinal recurrence. Of the 27 patients with anal fistulas, 11 were of the low-anal type, whereas 14 were anorectal. Conventional laying open of the fistula was undertaken in all patients with classical Crohn's disease in close conjunction with resection of the intestinal disease. On local surgical treatment 10 of 12 (89%) healed with preservation of continence. Four recurrent fistulas occurring in conjunction with intestinal recurrence also healed uneventfully. Laying open was undertaken in 11 of the 15 patients with colitis. Healing was obtained in only 4 of these patients. In the remaining 4 severe colitis indicated immediate proctocolectomy. Occurrence of fistulas involved a significant delay in perineal healing after proctectomy. It is concluded that traditional laying open of an anal fistula in patients with classical Crohn's disease is followed by high rate of uneventful healing. In contrast, local surgical treatment of anal fistulas complicating Crohn's colitis is usually unsuccessful. These patients are generally suffering more from the intestinal disease than from the fistula and should probably be offered proctocolectomy at an early stage.

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Résumé L'incidence et le pronostic des fistules anale ont été étudiés par une étude prospective comprenant 136 malades opérés pour maladie de Crohn. L'incidence de fistule anale était de 27/136 cas (20%) soit 12/68 chez des patients avec une maladie classique (18%) et 15/68 (22%) chez les malades qui avaient une colite de Crohn. Une fistule a prócédé la manifestation intestinale de la maladie chez 6 malades. A l'époque du diagnostic de maladie de Crohn, une fistule anale a été observée chez 19 malades comprenant 3 des 6 avec un début précoce ayant résistés au traitement, et demeurant active. 5 patients ont developpé des lésions anales durant l'evolution de la maladie, tous sauf 2 ont une relation de temps avec une récidive intestinale. Des 27 malades avec fistule anale, 11 étaient anales basses tandis que 14 étaient ano-rectales. Une mise à plat conventionnelle de la fistule a été réalisée chez tous les patients avec une maladie de Crohn classique en étroite conjonction avec la résection de la maladie intestinale. 10/12 ont cicatrisé localement après traitement chirurgical local (89%) avec préservation de la continence. 4 fistules récidivantes survenant conjointement à une récidive intestinale ont aussi guéri sans problème. La mise à plat a été réalisée chez 11 des 15 patients avec une colite. La cicatrisation fût seulement obtenues chez 4 de ces malades. Chez les 4 malades restants, une colite sévère a posé l'indication d'une proctocolectomie immédiate. La survenue de fistule provoque un retard significatif dans la cicatrisation périnéale avec protectomie. On conclut que la mise à plat traditionnelle d'une fistule anale chez les patients avec une maladie de Crohn classique est suivie par un taux élevé de cicatrisations correctes. Par contre, un traitement chirurgical local d'une fistule anale compliquant une colite de crohn est beaucoup plus souvent suivi d'insuccés. Ces malades souffrent généralement plus de leur maladie intestinale que de leur fistule et devraient probablement être proposés pour une proctocolectomie à un stade précoce.

     

Anal fissure in Crohn's disease: A plea for aggressive management

PURPOSE: This study was undertaken to identify clinical characteristics, natural history, and results of medical and surgical treatment of anal fissures in Crohn's disease. METHODS: This is a retrospective review of patients with Crohn's disease and anal fissure. RESULTS: Of the 56 study patients, 49 (84 percent) had symptomatic fissures. Fissures were most commonly (66 percent) located in the posterior midline, and 18 patients (32 percent) had multiple fissures. Fissures healed in one-half of patients treated medically. Factors predictive of successful medical treatment included male gender, painless fissure, and acute fissure. Of 15 patients, 10 (67 percent) treated surgically healed. Fissures in seven of eight patients (88 percent) who underwent anorectal procedures healed compared with fissures in only three of seven patients (43 percent) who underwent proximal intestinal resection. In the group of 50 patients with complete follow-up studies, an anal abscess or fistula from the base of an unhealed fissure developed in 13 patients (26 percent). More fissures healed after anorectal surgery (88 percent) than after medical treatment alone (49 percent; P=0.05) or after abdominal surgery (29 percent; P=0.03). CONCLUSION: This series documents that unhealed fissures frequently progress to more ominous anal pathologic disease. Judicious use of internal sphincterotomy appears to be safe for fissures unresponsive to medical treatment.     

Clinical literature review of 1858 Crohn's disease cases requiring surgery in China

AIM: To summarize the clinical characteristics of Crohn’s disease (CD) patients who underwent surgery in China.METHODS: We searched four main Chinese electronic databases: CBM, VIP, CNKI, and Wanfang (from January 1990 to October 2013). Then, we selected and carefully read 97 studies and extracted the surgical data for CD. We found that 1858 patients with CD underwent surgery between 1961 and 2012. The patients were stratified into two groups according to the year of surgery: 1961-2000 and 2000-2012. The clinical characteristics of these CD cases were compared between the two groups.RESULTS: The mean age at the time of surgery was 38.13 years. The most common locations of disease were the small intestine (40.84%), the colon (33.60%) and the ileocolon (23.09%). The primary indications for surgery were intestinal obstruction or stricture (23.84%), failure of drug therapy (14.80%), acute abdominal disease (13.46%), abdominal mass (10.93%), intestinal fistulae (9.90%), intestinal perforation (8.45%), perianal disease (6.73%), gastrointestinal bleeding (4.79%), and abdominal abscess (4.04%). The rate of diagnosis of CD before surgery was low (34.78%), and the misdiagnosis rate was 20.49%. The predominant surgical procedure for CD was bowel resection (69.54%). The rate of surgical complications was 20.34%, and the primary complications of surgery were infection (39.44%) and intestinal fistulae (26.09%). The relapse rate after surgery was 27.71%. For the periods of 1961-2000 and 2000-2013, the rates of both misdiagnosis before surgery and surgery related-death decreased (34.90% vs 12.10%, P < 0.001, and 23.53% vs 5.26%, P < 0.001, respectively).CONCLUSION: The rates of surgical complications and misdiagnosis were higher, whereas the rate of CD-associated tumor and the relapse rate were lower in China than in West countries.     

Crohn's disease. Results of excisional surgery in 133 patients

Of a series of 133 patients treated surgically for Crohn's disease during the years 1962-78, 21 had recurrence after previous operations in other hospitals. In addition, 40 of the patients underwent altogether 52 reoperations for recurrent disease; hence the total number of operations was 185. Five patients died in the postoperative period (2.7%). There were five late deaths related to Crohn's disease. The annual recurrence rate after all operations performed was rather constant, averaging 13.1%, and the cumulative recurrence rate after 10 years was 76.1%. The annual rate of reoperation tended to decline, with a cumulative reoperation rate of 35.8% after 10 years. The recurrence rate was not significantly different after primary operations and operations for recurrent disease. There was a higher risk of relapse during the first 2 years after non-radical excision of diseased gut than after radical excision. At follow-up examination in 108 patients most were in good general condition. Only eight patients had severe, disabling symptoms with reduced working capacity.     

Clinical course of perianal fistulas in Crohn's disease.

The clinical course of perianal fistulas and associated abscesses was evaluated prospectively in 90 patients with Crohn's disease. Fistula type, rectal disease, faecal diversion, and immunosuppression were examined as prognostic indicators for fistula healing and recurrence. Median follow up was 22 months. The outcome was evaluated with life table analysis. Prognostic factors were analysed by multiple regression. Inactivation was achieved in all patients. The risks of recurrent fistula activity were 48% at one year and 59% at two years. Fistulas were healed in 51% after two years but reopened in 44% within 18 months of healing. Faecal diversion and absence of rectal disease decreased recurrence rates (p = 0.019/0.04) and increased healing rates (p = 0.005/0.017). The outcome in patients with trans-sphincteric fistulas was better than that in those with ischiorectal fistulas but worse than in patients with subcutaneous fistulas (p = 0.015 for healing; p = 0.007 for recurrent fistula activity). After initial treatment about 20% of the patients were symptomatic and about 10% had painful events per six month period. Incontinence was rare and did not increase during the study period. Perianal fistulas and associated abscesses can be controlled safely by simple drainage of pus collections. Frequent reinfection and re-opening after healing of fistulas are characteristic. Fistula type, rectal disease, and stool contamination influence the clinical course. Only a few patients, however, have continuous symptoms from perianal fistulas.     

Clinical relapse of Crohn's disease under standardized conservative treatment and after excisional surgery

The course of 205 patients with Crohn's disease at one gastroenterological center was studied in patients with conservative drug treatment or with operative management of their disease. The decision for one or the other treatment regimen was made by an interdisciplinary team of gastroenterologists and surgeons. Using life-table analysis the 205 patients showed a clinical relapse rate of 27% after two years and 38% after four years. Clinical relapse was defined by a Crohn's disease activity index (CDAI) over 150. We used a standardized drug regimen of salazosulfapyridin and prednisone; the indication for excisional surgery was limited strictly to life-threatening situations, absolute nonresponse to drug treatment, and severe intervisceralfistulae. The operated patients (N=93) had a lower relapse rate than the patients treated conservatively (N=112), 20% and 51%, respectively, after four years. There were considerably fewer relapses in Crohn's colitis patients who were operated upon than in conservatively treated patients (18% versus 67% after four years); the same was found for ileocolitis (20% vs 49% after four years), but there was no difference between the treatment groups in ileitis (25–30% relapses for both after four years). In addition the patients with Crohn's disease of the colon had a more favorable course after resection with respect to symptoms, clinical and laboratory findings, and CDAI in remission. This paper gives data only for surgery in severe clinical situations and does not give a rationale for earlier surgery. This problem should now be studied in a randomized trial.     

Anal fistula. Its treatment and results

Between January, 1986 and December, 1988, 84 patients with anal fistula were operated on. Sixty-six were males and 18 females, with a mean age of 36 years. There was 100% follow-up. Parks' classification (1976) was used, with the following distribution: 65% transsphincteral 23% intersphincteral, 10% subcutaneous and 1% suprasphincteral fistulas. Fistulotomy and flattening were performed in every case but four, in which a seton ligature was used, performing a partial fistulotomy. Goodsall's rule was followed in 96.5% of the cases. The mean length of hospital stay was 2.1 days. Morbidity was 3.5% and the recurrence and gas incontinence rates were 4.7% and 3.5%, respectively. It was concluded that Parks' classification and Goodsall's rule are very useful in fistular surgery and that section of 3/4 of the sphincter does not increase the rate of incontinence, although a seton must be used in 5% of the cases with a 50% failure rate.     

Clinical presentation of Crohn's disease. association between familial disease, smoking, disease phenotype, extraintestinal manifestations and need for surgery

BACKGROUND/AIMS: Recent molecular data suggest that genetic factors may underlie the disease heterogeneity observed in Crohn's disease (CD). It was also suggested that familial inflammatory bowel disease (IBD) is a homogenous subgroup, phenotypically different from sporadic disease. Our aim was to determine the clinical presentation in a large CD population. METHODOLOGY: 564 CD patients (m/f: 278/286, age: 37.4 (SD 12.7) yrs, duration: 8.4 (7.1) yrs) were included. Disease phenotype was determined according to Vienna classification. Familial disease, extraintestinal manifestations (EIM), need for surgery and smoking habits were also analyzed. RESULTS: Familial IBD was present in 73 (12.9%) patients. Age at onset and presence of EIMs was associated with familial disease. Penetrating (44.6% vs. <10 yrs: 29.1%, P<0.0001) and ileocolonic disease (54.4% vs. 42.8%, P=0.03) were more common in patients with a disease duration of > or =10 yrs. In a logistic regression model female gender, colonic/ileocolonic location, smoking and familial IBD were independent risk factors for EIMs, while ileal and non-inflammatory disease increased the risk for resections. Smoking was also associated with frequent relapses. CONCLUSIONS: Familial IBD was associated with the presence of EIMs, while ileal involvement and noninflammatory behavior independently increased the risk for surgery. Since penetrating and extensive disease was more frequent in patients with longer disease duration our data support a possible change in location and behavior during the course of disease.     

8 Place of laparoscopic surgery in Crohn's disease

Laparoscopic surgery for patients with Crohn's disease is feasible and safe. It may be conducted in appropriately selected patients including those with localized abscess, phlegmon, simple intra-abdominal fistulas, and perianastomotic recurrent disease. However, as the technique is just evolving and has yet to be shown to be of advantage over conventional open surgery, it should not be considered as a standard care. Randomized prospective clinical studies are needed to determine that laparoscopic surgery for Crohn's disease is at least equivalent or better than conventional open surgery.     

Laparoscopic surgery in the management of Crohn's disease

Crohn's disease is a chronic inflammatory bowel disease with surgery still frequently necessary in its treatment. Since the 1990's, laparoscopic surgery has become increasingly common for primary resections in patients with Crohn's disease and has now become the standard of care. Studies have shown no difference in recurrence rates when compared to open surgery and benefits include shorter hospital stay, lower rates of wound infection and decreased time to bowel function. This review highlights studies comparing the laparoscopic approach to the open approach in specific situations, including cases of complicated Crohn's disease.     

Laparoscopic surgery for complex and recurrent Crohn's disease

Crohn's disease(CD) is a chronic inflammatory disease of digestive tract. Approximately 70% of patients with CD require surgical intervention within 10 years of their initial diagnosis, despite advanced medical treatment alternatives including biologics, immune suppressive drugs and steroids. Refractory to medical treatment in CD patients is the common indication for surgery. Unfortunately, surgery cannot cure the disease. Minimally invasive treatment modalities can be suitable for CD patients due to the benign nature of the disease especially at the time of index surgery. However,laparoscopic management in fistulizing or recurrent disease is controversial. Intractable fibrotic strictures with obstruction, fistulas with abscess formation and hemorrhage are the surgical indications of recurrent CD,which are also complicating laparoscopic treatments.Nevertheless, laparoscopy can be performed in selected CD patients with safety, and may provide better outcomes compared to open surgery. The common complication after laparoscopic intervention is postoperative ileus seems and this may strongly relate excessive manipulation of the bowel during dissection. But additionally, unsuccessful laparoscopic attempts requiring conversion to open surgery have been a major concern due to presumed risk of worse outcomes. However, recent data show that conversions do not to worsen the outcomes of colorectal surgery in experienced hands. In conclusion, laparoscopic treatment modalities in recurrent CD patients have promising outcomes when it is used selectively.