Course of enterovesical fistulas in Crohn's disease

Enterovesical fistulas occurred in 38 of 683 patients (5.6 percent) with Crohn's disease admitted to The Mount Sinai Hospital between 1960 and 1977. There were 22 ileovesical fistulas, 8 colovesical fistulas, and 8 fistulas of combined ileal and colonic origin. These cases fell into three different pathophysiologic categories: 16 patients presented with sepsis after a mean duration of 7 years of Crohn's disease, 19 presented without sepsis after a mean of 10 years of disease, and 3 elderly cancer patients presented with an average 25 years disease duration. Sepsis was usually due to deep pelvic or lower quadrant abscess with spontaneous rupture into the bladder. Nonseptic fistulization was a later, more gradual process, reflecting slow penetration into the bladder from a site of chronic cicatrizing bowel disease. Cancer was a very late complication, arising in each patient from an excluded loop. Although medical treatment was successful in delaying surgery in 6 patients and obviated surgery altogether in 2 patients, 36 of 38 patients (95 percent) eventually required operation. Postoperative mortality in this series was limited to two patients (5 percent) with preoperative intraabdominal abscess and sepsis. Five other deaths, unrelated to urinary complications, were caused by intestinal cancer in three patients and by intestinal complications of recurrent Crohn's disease in two patients. The urologic course of patients with enterovesical fistula was completely benign. All operated patients were cured of their enterovesical fistulas, and no urologic sequelae developed. Subsequent reoperations that were required in 45 percent of these patients were all for recurrent bowel disease and not for fistula or other urologic problems.     

Perianal fistulas in patients with Crohn's disease

A series of 55 patients with perianal fistulas and Crohn's disease is reported herein. Thirteen patients (24%) did not need specific treatment of the fistula. Primary proctectomy was necessary in five patients. Defunctioning enterostomy was used in nine patients, followed by healing of the fistula in four patients. Local surgery of the fistula was performed in 28 patients, with an overall success rate of 79%. Healing of the fistula was not influenced by activity of the disease, type of fistula, or condition of the rectum. Local surgery did not cause incontinence in this series.     

Stapled fistulectomy to treat enteroenteric fistulas in Crohn's disease

We report herein our technique of performing stapled fistulectomy as minimum surgery for the resection of nine entero-enteric fistulas in six patients with Crohn's disease. The surgical outcome was successful in all patients. It would seem that fistulous sites without a severe affected lesion are a favorable indication for this procedure and we recommend this simplified fistulectomy for selected conditions in Crohn's disease.     

Diagnosis and treatment of duodenoenteric fistulas complicating Crohn's disease

A duodenoenteric fistula is an unusual complication of Crohn's disease that requires surgical intervention and may present a difficult management problem. Eleven patients with this condition were treated with an ileocolectomy with primary anastomosis and closure of the duodenal defect after take-down of the fistula. In all patients, the duodenal tissues were free of pathologic evidence of Crohn's disease. The fistula was found to result from Crohn's disease limited to the ileocolonic segment or from anastomotic complications in some patients who had previously undergone ileocolonic resections. Satisfactory healing at the ileocolonic anastomosis and at the duodenal closure site occurred in ten patients; breakdown of the duodenal closure leading to sepsis and death occurred in one patient with an unusually large defect in the first portion of the duodenum. In most instances, these fistulas can be treated safely and adequately by resection of the diseased intestinal segment and simple direct duodenal closure. However, safe management of large duodenal defects may require the use of other methods, such as a serosal patch or creation of a duodenojejunostomy.     

Management of Crohn's disease

Our therapeutic management to Crohn's disease was analyzed retrospectively. Among 17 cases with Crohn's disease, 14 (82%) were operated. Operative indications were due to obstruction (7), perforation (2), fistula (2), stenosis (2) and intractability (1). Postoperative recurrence was developed in 8 out of 14 (57%) and 4 were reoperated. Most of recurrent lesions were around the previous anastomosis. Operation per se does not cure the Crohn's disease but operation should be indicated when complicated obstruction, fistula and perforation. Nutritional treatment has been also performed 8 times. Crohn's disease activity index (CDAI) was decreased in all but one. In individual item of CDAI, frequency of bowel movement, abdominal pain and general status were improved but items such as anal lesion, fistula and fever were not improved. CDAI values were turned to remission value in all of cases with complicated stenotic lesions, but it remained in active stage in all cases with complicated fistula, obstruction and abscess. Nutritional treatment seemed less effective in cases complicated fistula, obstruction and abscess.     

Diagnosis and management of enterovesical fistulas in patients with Crohn's disease

The objective of this study was to investigate the clinical manifestations and diagnostic studies used to evaluate Crohn's patients with enterovesical fistulas (EVFs) and to assess outcome after surgical intervention. This is a ten year multi-institutional retrospective chart review of patients with Crohn's disease. Of 400 patients identified with Crohn's disease eight (2%) were diagnosed with EVF. The mean age at diagnosis was 27 years. No patients had prior surgeries for Crohn's. Duration of symptoms ranged from 6 months to 15 years. There were seven ileovesical and one colovesical fistula identified. One patient had associated perianal disease. Three had concomitant enteroenteral fistulae. Clinical features included pneumaturia in seven patients (88%), fecaluria in three (38%), hematuria in five (63%), and urinary tract infection symptoms in seven (88%). Diagnostic studies included CT scan in six, barium or gastrografin enema in four, and cystoscopy in four. Surgical therapy involved resection of the affected bowel. The bladder defect was closed primarily in two layers in all patients using absorbable suture, with omental patch in four. Two patients underwent ileostomy and one underwent colostomy, all taken down within 6 months. There were no bladder leaks and no anastamotic leaks. There were no perioperative deaths. The mean postoperative stay was nine days. The mean follow-up was 39 months. We conclude that pneumaturia is a strong clinical indicator of EVF. CT has been valuable in identifying gas within the bladder in these patients. Cystoscopy has proven useful in identifying the fistulous tract and in evaluation of the ureters. The presence of an EVF should heighten suspicion as to the presence of concomitant enteroenteral fistulae. Barium or gastrografin studies are useful in this capacity. Surgical treatment of EVFs should include resection of affected bowel. The bladder defect can safely be closed using absorbable suture.     

Management of perianal Crohn's disease

Most patients with perianal Crohn's disease are asymptomatic and perianal disease may resolve given adequate medical treatment for the underlying intestinal lesion. This will consist principally of sulphasalazine and prednisolone, both of which are known to be effective in the treatment of Crohn's disease. Should the local perianal disease become more severe, a trial of oral metronidazole may be worthwhile. The development of an ischiorectal or perianal abscess is an indication for the simplest surgical drainage procedure, and rectal strictures resulting from the healing of perianal fissures may be gently dilated. Further progression of disease may be treated by diversion of the fecal stream, but this will stand a greater chance of success in patients without florid rectal Crohn's disease. Fecal diversion is also indicated as a preliminary to the repair of rectovaginal fistulas. Patients with florid perianal Crohn's disease and severe anorectal disease will probably come to proctocolectomy, but initial defunctioning of the colon will make the operative procedure easier, may facilitate perineal healing, and some patients may actually avoid proctectomy with its high risk of a persistent perineal sinus.

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Resumen La mayor parte de los pacientes con enfermedad de Crohn perianal permanecen asintomáticos y pueden exhibir resolución con el tratamiento médico adecuado de la enfermedad intestinal de base. Este consiste, principalmente, de Salazopirina y prednisolona, drogas de conocida efectividad en la terapia de la enfermedad de Crohn. En el caso de que la enfermedad perianal local se haga más severa, puede justificarse un ensayo con metronidazol oral. El desarrollo de un absceso isquiorrectal o perianal constituye indication para el procedimiento de drenaje quirÚrgico más simple que sea posible, y las estenosis rectales resultantes de la cicatrización de fisuras perianales pueden ser sometidas a dilatación delicada. La progresión de la enfermedad puede ser manejada mediante desviación del torrente fecal, pero existe mejor posibilidad de éxito en pacientes sin enfermedad rectal florida. La desviación fecal también está indicada como un procedimiento preliminar a la reparación de las fístulas rectovaginales. Los pacientes con enfermedad perianal florida y severa enfermedad anorrectal probablemente habrán de requerir proctocolectomía, pero la desfuncionalización inicial del colon facilita la operación, puede estimular la cicatrización perianal, y en algunos pacientes logra evitar la proctectomía con su alto riesgo de fístula perianal persistente.

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Résumé Dans la majorité des cas la maladie de Crohn périanale est asymptomatique et répond favorablement à un traitement médical adéquat de la lésion intestinale initiale, traitement consistant essentiellement en l'emploi de la Salazopyrine et de la prédnisolone dont l'efficacité est reconnue. Les lésions deviendraient—elles plus intenses qu'un essai de traitement oral par le métronidazole peut Être couronné de succès. La constitution d'un abcès ischio-rectal ou périanal relève simplement d'une intervention de drainage alors que les sténoses rectales consécutives à la cicatrisation de fissures périanales peuvent Être traitées par dilatation douce. Si la maladie progresse il peut Être nécéssaire d'établir une dérivation intestinale, les chances de succès étant d'autant plus grandes que la maladie de Crohn n'est pas active. La dérivation intestinale constitue l'intervention préliminaire au traitement d'une fistule recto-vaginale. Lorsque la maladie de Crohn périanale est active et les lésions ano-rectales sont graves, il devient nécessaire de procéder à une proctocolectomie. Dans ce cas, la dérivation intestinale préalable rend l'intervention plus facile, la cicatrisation plus aisée et évite chez quelques malades la constitution d'une fistule permanente après la protectomie.

     

Management of urinary complications in Crohn's disease

Among the 127 patients who underwent surgical treatment for Crohn's disease at Tohoku University Hospital, urinary complications were noted in 13 patients (10.2%), including urolithiasis in 6 patients (4.7%), a ureteral obstruction in 4 (3.1%), and urinary fistula in 3 (2.4%). In patients with urolithiasis, conservative therapy was effective. An ureteral obstruction was detected on the right side in all 4 of these cases because of the inflamed terminal ileum. In 2 of the 4 cases, the symptoms improved by either preoperative total parenteral nutrition or elemental diet therapy. A resection of the inflamed intestine was necessary in all cases. In patients with urinary fistulas, a resection of the inflamed intestine combined with a reconstruction of the urinary tract was carried out after total parenteral nutrition. In conclusion, conservative therapy with preoperative total parenteral nutrition or elemental diet therapy proved to be effective for a ureteral obstruction since it improved the intestinal inflammation. As a definitive treatment, surgery is still necessary for the management of urinary fistulas and ureteral obstruction. Based on our findings, patients with urolithiasis in Crohn's disease should thus be treated conservatively in the same way as patients without Crohn's disease.     

Management of urinary complication in Crohn's disease

PURPOSE: Although urinary complications of Crohn's disease are relatively rare, they often present diagnostic and therapeutic dilemmas. However, there is no established strategy for treating urinary complications of Crohn's disease. In the present clinical study, we describe the frequency of urinary complications of Crohn's disease, and discuss various approaches to their diagnosis and treatment. PATIENTS AND METHODS: The subjects were 1,551 patients who underwent medical treatment for Crohn's disease between January 1994 and May 2002 at Social Insurance Central General Hospital. The subjects were retrospectively evaluated. RESULTS: Urinary complications occuered in 75 of the 1,551 patients (4.8%): urolitiasis in 60 patients, urinary fistula in 14 patients, and urachal abscess (Enterourachocutaneous fitulas) in 1 patient. A total of 41 of the 75 patients with urinary complications (55%) consulted a practicing urologist: 26 patients with urolithiasis, 14 patients with urinary fistula and 1 patient with urachal abscess. 26 patients with urolithiasis received medical treatment: 20 patients underwent conservative therapy, 4 patients underwent ESWL, and 2 patients underwent TUL. In all 26 of those cases, the treatment was successful. Twelve of the 14 patients with urinary fistulas (86%) underwent resection of the inflamed intestine combined with reconstruction of the urinary tract. The 1 patient with urachal abscess underwent resection of the urachus and the inflamed intestine, and partial cystectomy. CONCLUSION: All patients with urolithiasis should be treated the same way, whether or not they have Crohn's disease. In patients with Crohn's disease complicated by urinary fistula, surgery should be performed after preoperative medical therapy, as it improves the quality of life of such patients more rapidly than other approaches and may help avoid intestinal resection.     

Management of intra-abdominal abscesses in Crohn's disease.

Over a 5-year period, 54 intra-abdominal abscesses were observed in 40 (20.8%) of 192 patients with Crohn's disease. The median age was 39 years (range 17-76 years); median interval from diagnosis, 7.5 years (range 0-24 years) and the median number of surgical operations was 2 (range 0-7). Forty abscesses (74.1%) were spontaneous and 14 (25.9%) were postoperative. Thirty abscesses were initially managed by laparotomy, 14 by percutaneous drainage, nine by incision and drainage and in one case the abscess drained spontaneously. Intra-abdominal abscesses were managed successfully by laparotomy in 23 (76.7%) of 30 patients, with a 93% success rate (13 of 14) for spontaneous abscesses managed by resection and primary anastomosis. Three of 8 (37.5%) spontaneous abscesses were managed successfully by percutaneous drainage, a temporising effect being achieved in a further two cases. There was no significant difference in sepsis score or duration of hospital stay for patients managed initially by laparotomy and those managed by drainage. However, patients with stricturing or fistulating Crohn's disease were much more likely to have initial management by laparotomy and in these patients surgical intervention was found to be an effective initial strategy.     

Seton treatment for perianal Crohn's fistulas

In this study, we evaluated the efficacy of long-term seton drainage in the management of 13 patients with severe perianal Crohn's fistulas which had proven to be intractable to conventional therapy. After adequate curettage of the fistulous tracts and infected tissue, either a Penrose drain or a fine polyethylene catheter was inserted to encircle the tracts and tied. Patients were followed up for a mean period of 12.1 months. Perianal pain disappeared or improved in all 13 patients, while the body temperature of all 7 with pyrexia dropped to within the normal range. Discharge disappeared or diminished in 77% (10/13) and tenderness disappeared or improved in 77% (10/13). Induration disappeared or improved in 69% (9/13). Overall, good results were achieved in 10 patients, although 3 required redrainage. In one of these patients, a good result was achieved after colostomy was performed for active intestinal disease. Nevertheless, 2 patients did not improve, one of whom required lay-open surgery after seton treatment. In 8 of the 13 patients, some seton drains were able to be removed, and none of the patients experienced any soiling or leakage. Thus, we conclude that seton treatment is worthwhile in the management of perianal Crohn's fistulas as it alleviats the symptoms and simplifies multiple tracts. Moreover, it preserves sphincter function, is less invasive, and can be managed easily.     

Management of Crohn's disease and ulcerative colitis

Crohn's disease and ulcerative colitis (UC) are complex, contrasting disease processes that require multidisciplinary team management. The treatment modalities in inflammatory bowel disease are varied and the indications and threshold for surgery quite different in patients with UC compared with Crohn's disease. We discuss the panoply of surgical techniques available to the surgeon and IBD-patient whilst highlighting the potential sequelae, complimentary medical therapies, nutritional considerations and innovative techniques for reconstruction of the gastrointestinal tract.     

Management of enterovesical fistula in patients with Crohn's disease

PURPOSE: Enterovesical fistula in patients with Crohn's disease is intractable. Although there are some reports that the enterovesical fistula were successfully treated conservatively, closure of the fistula cannot always be achieved and surgical intervention may required for those patients. Since surgical closure of entero-entero fistula has a high risk of relapse, the strategy for treating enterovesical fistula has not been established. We evaluated the clinical findings especially in management of enterovesical fistula in Crohn's disease. PATIENTS AND METHODS: Two hundred two patients (mean age was 28.4 year old, range 12-69; 152 men and 50 women) were diagnosed as Crohn's disease during a period of 15 years between 1986 and 2000 in our institute. The incidence and the clinical results regarding the diagnosis and the treatment of enterovesical fistula in these patients were retrospectively evaluated. RESULTS: Seven in 202 patients were diagnosed to have an enterovesical fistula (3.5%, 6 men and 1 woman). The period from the initial diagnosis of Crohn's disease to the recognition of the enterovesical fistula was 11 to 204 months (mean 92.1 months). Enterovesical fistula was revealed and/or visualized by radiological enterography in 6, cystography in 2, cystoscopy in 6, and CT in 4 patients. Surgical interventions were finally conducted in all 7 patients after the failure of conservative treatment for 10 to 146 days (mean 68.2 days). Surgical procedures performed for closing the enterovesical fistula were partial cystectomy with fistulectomy in 5, fistulectomy with bladder wall overlay-suture in 2, and bladder wall overlay-suture alone in 1. No relapse of enterovesical fistula was recognized in any patient in the average observation of 41.6 months. CONCLUSION: Although the treatment of Crohn's disease has been advanced, enterovesical fistula is shown to be resistant to conservative treatment options and it makes patients in unfavorable status for relatively long duration. Our evaluation shown here demonstrated the sufficient surgical results on the closure of enterovesical fistula without any relapse, and was different from the high relapse rate after the surgical management of entero-entero fistula in similar observation period. Surgical interventions of enterovesical fistula caused by Crohn's disease might have an advantage to make diseased patients improved in shorter duration.     

Carbon dioxide laser ablation of perianal fistulas in patients with Crohn's disease: experience with 27 patients

BACKGROUND: Perianal fistula disease (PAD) occurs in up to 40% of patients with Crohn's disease (CD). Medical therapy is often unsuccessful, and, with surgical therapy, healing is unreliable and management is frequently painful and unsatisfactory. Outpatient CO(2) laser ablation of PAD has emerged as an alternative. METHODS: Twenty-seven patients were evaluated by chart review. The severity of PAD based on a 5 category scoring system was collected. Scores were recorded at the time of surgery and at each subsequent postoperative visit. RESULTS: Differences between PAF severity scores were significant for the initial operation versus postoperative visit 1 (P < .001) and for the initial operation versus the final visit (P < .001). Variation in the postoperative PAD score was affected by the score in the operating room and colonic involvement of CD. CONCLUSION: CO(2) laser ablation therapy successfully treats PAD; many fistulas are completely healed and others are converted into a single, minimally draining fistula with this well-tolerated outpatient procedure.     

Challenges in Crohn's disease: Complex perianal Crohn's disease

Perianal disease is a particularly morbid phenotype of Crohn's disease with significantly diminished quality of life, affecting up to a third of patients. Medical therapies achieve long term durable remission in only a third of patients. Thus, most undergo operative intervention, at the expense of a risk of incontinence. Mesenchymal stem cell therapy is an emerging therapy without risk of incontinence and improved efficacy as compared to conventional therapy. Additional manifestations of perianal Crohn's disease including hemorrhoids and skin tags are possible to manage operatively, only in the absence of proctitis and anal canal disease.     

Three-dimensional modelling as a novel interactive tool for preoperative planning for complex perianal fistulas in Crohn's disease

Aim

The aim of this study is to demonstrate the added value of three-dimensional (3D) reconstruction models and artificial intelligence for preoperative planning in complex perianal Crohn's disease. MRI is the gold standard for diagnosis of complex perianal fistulas and abscess due to its high sensitivity, but it lacks high specificity values. This creates the need for better diagnostic models such as 3D image processing and reconstruction (3D-IPR) with artificial intelligence (AI) algorithms.

Method

This is a prospective study evaluating the utility of 3D reconstruction models from MRI in four patients with perineal Crohn's disease (pCD).

Results

Four pCD patients had 3D reconstruction models made from pelvic MRI. This provided a more visual representation of perianal disease and made possible location of the internal fistula orifice, seton placement in fistula tracts and abscess drainage.

Conclusion

Three-dimensional reconstruction in CD-associated complex perianal fistulas can facilitate disease interpretation, anatomy and surgical strategy, potentially improving preoperative planning as well as intraoperative assistance. This could probably result in better surgical outcomes to control perianal sepsis and reduce the number of surgical procedures required in these patients.     

Management of enterovesical fistulas

The records of 51 patients diagnosed with enterovesical fistulas at Virginia Mason Medical Center from 1974 to 1988 were reviewed. Diverticulitis (41%), Crohn's disease (17%), and colorectal cancer (16%) were the major causes. In 50 of 51 patients, the diagnosis was made on the basis of the clinical history and the urine culture. Radiologic and endoscopic studies failed to identify the fistula in 20%, though all were confirmed at operation or autopsy. In four of eight patients with fistulas secondary to colorectal cancer, malignancy was not diagnosed preoperatively. Operation was performed in 84% of the patients. One-stage resection of the bowel was performed in 66% of patients with the intent of removing the fistula. The complication rate was 8% with no deaths. All multi-stage procedures were performed for fistulas complicated by abscess or bowel obstruction. There were two postoperative deaths in patients with metastatic cancer undergoing palliative diversion. All eight patients treated by diverting colostomy had persistent fistulas and urinary sepsis. All eight patients treated with antibiotics but without operation were free of complications of the fistula until death from other causes. Enterovesical fistula is a clinical diagnosis. Preoperative studies should be used to delineate the bowel disease and search for malignancy rather than to see the fistula, which is clinically apparent. One-stage resection of the involved bowel is the procedure of choice in the absence of abscess or bowel obstruction. When resection is not feasible, medical management with antibiotics is preferable to colostomy.