Perianal abscess in Crohn's disease

PURPOSE: Perianal disease is frequent in patients with Crohn's disease, and many of these patients will eventually have abscess formation. In a prospective follow-up study, we evaluated factors influencing the occurrence and recurrence of perianal abscesses. METHODS: Of 126 consecutive patients with perianal Crohn's disease seen regularly in an outpatient clinic, 61 (48.4 percent) had at least one perianal abscess (mean follow-up, 32±17 months). In all, 110 episodes of an abscess with 145 anatomically distinct abscesses were documented. RESULTS: The occurrence of first abscesses was dependent on the type of anal fistula (ischiorectal, 73 percent; transsphincteric, 50 percent; superficial, 25 percent;P < 0.02). Surgical therapy consisted of seton drainage (34 percent), mushroom catheter drainage (49 percent), or incision and drainage (29 percent) and led to inactivation in all patients. Cumulative two-year recurrence rates after the first and second abscess were 54 and 62 percent, respectively. Abscess recurrence was less frequent in patients with a stoma (13 vs. 60 percent in patients without stoma after two years) and in patients with superficial anal fistulas (0 vs. 55 percent/56 percent in patients with transsphincteric/ischiorectal fistulas). Only two abscesses recurred within one year after removal of seton drainage, whereas 13 abscesses recurred with the seton still in place. Neither intestinal nor rectal activity of Crohn's disease significantly influenced the occurrence of an abscess. During the study period, only two patients developed partial stool incontinence. CONCLUSION: Development of perianal abscesses in Crohn's disease depends on the fecal stream and the anatomic type of anal fistula. Seton and catheter drainage are safe and highly effective in treatment. Long-term use of setons to prevent recurrent abscesses is not supported by our data.     

Fistula-in-ano in Crohn's disease

The outcome of aggressive surgical treatment of 64 symptomatic anal fistulas in 55 patients with Crohn's disease has been studied. Forty-one fistulas, in 33 patients, were treated by conventional fistulotomy (17 subcutaneous, 19 intersphincteric, 5 low transsphincteric fistulas). Thirty wounds (73 percent) healed within 3 months and eight more wounds (93 percent) healed within 6 months. Three wounds did not heal within 12–18 months. Two of these patients subsequently required proctocolectomy. Wound healing was not influenced by the presence of rectal Crohn's disease or granulomatous inflammation in the tract. No change in continence was experienced by 26 of the 33 patients who underwent fistulotomy. Three patients required proctocolectomy and the remaining four patients experienced minor degrees of incontinence postoperatively. Sixteen high transsphincteric, five suprasphincteric, and one extrasphincteric fistula in 22 patients were treated by laying open external tracts and placing a noncutting seton through the sphincter, which was left in place for prolonged periods to maintain drainage. During follow-up (6 months to 10 years, median 2.5 years), three fistulas healed and seven remained quiescent. Nine patients required further treatment by a new seton and three patients required proctocolectomy. Eight of the 22 patients who had a seton inserted had no change in continence, and six patients in this group developed minor changes in continence, mostly related to diarrhea associated with intestinal disease. Anal fistulas in Crohn's disease, which involve minimal sphincter muscle, can be successfully treated by fistulotomy. High fistulas should be treated with seton drainage to limit recurrent suppuration and preserve sphincter function.Read at the 89^th meeting of the American Society of Colon and Rectal Surgeons, St Louis, Missouri April 29–May 4 1990.     

Evaluation of surgery for perianal Crohn's fistulas

PURPOSE: This study was designed to evaluate the operative treatments performed on patients with perianal Crohn's disease at a tertiary referral colorectal university hospital and to determine the efficacy of management by assessing patient satisfaction. METHODS: A retrospective survey included 59 patients with perianal Crohn's disease who had undergone surgery during the period of 1991 to 1993, inclusive. RESULTS: Twenty-seven patients were treated by laying the fistula open (81 percent successful), and another 27 cases were treated with a loose seton (85 percent successful). Five cases were complicated fistulas and underwent diversionary stomas as part of a primary procedure. Overall success rate, as judged by patient satisfaction, was 83 percent. CONCLUSION: Conservative surgery has a role in management of perianal Crohn's disease. Patient satisfaction can be achieved without complete healing. Better preoperative assessment may improve results further.     

Perianal Bowen's disease

PURPOSE: Perianal Bowen's disease is an uncommon squamous-cell carcinoma in situ usually treated by surgical excision. There are controversies concerning surgical margin extent, because the disease is likely to recur in nonexcised skin areas of the anal and perianal skin. The aims of this study were 1) to determine the recurrence rate after different surgical treatments and 2) to determine if molecular markers might have a prognostic role in perianal Bowen's disease. METHOD: Retrospective chart review from 1972 to 1993 of 47 patients with perianal Bowen's disease was undertaken. Follow-up was obtained by office visits and/or phone questionnaire. Immunohistochemical analysis for p53 protein and Ki-67 nuclear antigen was conducted on fixed tissue specimens. RESULTS: Twenty-six patients were treated by wide local excision with microscopic clearance of resection margins, 15 by local excision with only macroscopic clearance of resection margins, 5 by CO ₂ laser vaporization, and 1 by abdominoperineal resection because of fecal incontinence. Median follow-up for the entire population was 104 (range, 16–273) months. The incidence of local recurrence was 23.1 percent (6/26) after wide local excision, 53.3 percent (8/15) after local excision, and 80 percent (4/5) after CO ₂ -laser vaporization. Recurrence rate estimated by Kaplan-Meier analysis is statistically different ( P =0.002) between radically treated patients (wide local excision/abdominoperineal resection;n =27) and patients undergoing conservative treatment (local excision/laser vaporization;n =20). Among patients with recurrence, the median time until recurrence was 38.5 (range, 3–89) months and 41.5 (range, 4–111) months after conservative and radical treatment, respectively. Nine of 20 (45 percent) patients in the conservative group and none of the 27 patients in the radical group had multiple episodes of recurrence ( P <0.001). In addition, 3 of 20 and 0 of 27 patients in the respective groups developed an invasive cancer ( P =0.034). Positive staining for p53 protein was observed in 12 (33.3 percent) of the 36 tissue specimens available for immunohistochemical analysis. Recurrence occurred in 9 of 24 (37.5 percent) patients negative for p53 and in 6 of 12 (50 percent) patients with positive p53 expression ( P =not significant). Ki-67 antigen-graded expression from 1+ to 4+ did not reveal any correlation with incidence of recurrence. Recurrence rate did not differ by p53 and Ki-67 results, either in the overall group of 36 patients or stratified by surgical treatment groups. CONCLUSION: Wide local excision for perianal Bowen's disease leads to a significantly lower recurrence rate than local excision or laser therapy. Follow-up longer than five years is recommended because of the risk of late recurrence. p53 protein and Ki-67 antigen immunohistologic expression may not have a prognostic role in perianal Bowen's disease.Supported by the John Wilson Memorial Fund, Cleveland Clinic, Cleveland, Ohio.Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Perianal Bowen's disease

BACKGROUND: Perianal Bowen's disease (BD) is an intraepithelial nonkeratinizing carcinoma, associated historically with internal tumors. METHODS: A review of patients with perianal BD presenting consecutively during a 25-year span was undertaken, excluding Bowenoid papulosis and contiguous genital BD. Histologic slides were resubmitted for review by an experienced pathologist, in a blind fashion among other slides. Follow-up was updated in every patient. Survival and recurrence curves were generated by the Kaplan-Meier method and were compared with a normal age-matched population (log-rank test). RESULTS: Nineteen patients were identified; 15 of them were females. Mean age±standard deviation was 49.6±10.6 years. Five patients had a coincidental diagnosis (hemorrhoidectomy or wart excision). No associated carcinomas were found; however, eight patients had isolated BD of the vulva. Eleven patients had a history of anal warts, cervical/vulvar dysplasia, or both. Wide resection, including V-Y flaps, was performed in 18 patients without dysfunction. One-year and five-year recurrence was 16 and 31 percent. Recurrence was treated in all but one case by wider resection. Mean follow-up was 8.4 years. Five-year survival was 75 percent, lower than the matched population (P=0.001); however, only one death was related to BD. CONCLUSIONS: Perianal BD has no association with internal tumors. Despite a high rate of recurrence, perianal BD can be treated by local excision. An increased rate of human papilloma virus-related entities was found, which could suggest a causative role.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Abdominoperineal resection for severe perianal Crohn's disease

Despite the high incidence of involvement of the perianal region in Crohn's disease, excisional surgery seldom is required for perianal disease alone. Nine patients are presented who had severe perianal Crohn's disease, which eventually required abdominoperineal excision of the anorectum. In all nine patients, it was secondary manifestations of anal Crohn's disease that precipitated proctectomy, such as high fistulas, strictures, and rectovaginal fistulas. These secondary phenomena, especially fistulas caused by cavitating ulceration, become self-perpetuating by the mechanical effect of feces being forced into the tract. During the same period, 17 patients required rectal excision by abdominoperineal resection, where perianal disease was incidental to severe colorectal disease. There is a tendency for excessive delay before advising surgery for severe perianal disease. An attempt should be made to identify patients with a poor prognosis to avoid unnecessarily prolonged morbidity. Assessment of the exact nature of the anal lesion and assessment of Crohn's disease activity are important in making this decision.     

Factors predictive of persistent or recurrent Crohn's disease in excluded rectal segments

The fate of the excluded rectal segment after surgery for Crohn's colitis remains poorly defined. To determine prognostic factors relating to the fate of the rectal segment, records of 47 patients who underwent creation of an excluded rectal segment were studied. Disease developed in 33 patients (70 percent) in the excluded rectal segment by five years; 24 patients (51 percent) had completion proctectomy by 2.4 years; and 9 patients (19 percent) retained a rectum with disease at a median follow-up period of five years (range, 2–13 years). At a median follow-up time of six years (range, 2–21 years), 14 patients were without clinical disease. The three groups were equivalent with respect to sex, duration of preoperative disease, indication for operation, distribution of disease, and histologic involvement of the proximal rectal margin. The median age of patients in the proctectomy group at diagnosis tended to be younger than that of patients with a retained excluded rectal segment (22, 30, and 31 years for patients having proctectomy, patients with a diseased excluded rectal segment, and patients with a normal excluded rectal segment, respectively). Neither initial involvement of the terminal ileum nor endoscopic inflammatory changes seen in the rectum predicted eventual disease of the excluded rectal segment. However, initial perianal disease complicating Crohn's colitis was predictive of persistent excluded rectal segment disease and often required proctectomy. Therefore, because the presence of perianal disease and Crohn's colitis predicts persistent or recurrent excluded rectal segment disease, primary total proctocolectomy or early completion proctectomy may be indicated in this subgroup of patients.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.     

Management of perianal Crohn's disease

PURPOSE: Management of perianal Crohn's disease is still controversial, and reports on large series are very few in the literature. The aim of this multicenter study was to investigate the outcome of both medical and surgical treatment in 225 patients. METHODS: Patients cared for at different institutions were followed up for a median of six years. Most of them had either anal fistula or an abscess (86 percent and 43 percent, respectively), but fissures were also present in 26 percent of the cases. Diarrhea and anal pain were the most common symptoms. Anal lesions preceded the onset of intestinal symptoms in 19 percent of cases. RESULTS: Medical treatment was curative only in 21 of 123 patients. Overall, medical and surgical treatment either cured or improved 62 percent of the cases. Fifty percent had an intestinal resection. Abscess drainage and fistulotomy were the most common anal surgeries. Rectovaginal fistulas (n=30) required intestinal surgery in 36 percent and anal surgery in 20 percent of the cases, 50 percent with good results. Of 166 patients who had anal surgery, 97 (58 percent) had a positive outcome. Recurrence of anal disease requiring further surgery occurred in 24.5 percent of the cases. CONCLUSIONS: Limited surgeries seem to achieve satisfactory results in more than one-half of the patients affected by perianal Crohn's lesions, whereas medical treatment alone is curative in a small portion of them.Read at the Falk Symposium, Estoril, Portugal, May 6 to 8, 1994.     

Perirectal abscess in Crohn's disease

The role of surgical intervention in the treatment of patients with anorectal Crohn's disease is controversial. To clarify the success of aggressive drainage and the subsequent clinical course of patients with Crohn's disease and perirectal abscesses, the authors reviewed the records of 38 patients who presented with this condition during an eight-year period. Twenty-two male and 16 female patients (median age, 32 years; range, 17 to 61 years) with clinically or pathologically confirmed Crohn's disease of the bowel underwent operation for perirectal abscesses. Thirty-two percent of patients had no previous history of anorectal Crohn's disease. Thirty simple abscesses and 8 complex horseshoe abscesses were treated. At operation, 53 percent of patients underwent incision and drainage whereas 26 percent received loop indwelling drains and 21 percent had mushroom catheters placed. After resolution of the index abscess, recurrent abscesses occurred in 45 percent of the patients who underwent catheter drainage and 56 percent of the patients who underwent incision and drainage. More importantly, 44 percent of the incision and drainage group and only 31 percent of the catheter drainage group required subsequent proctectomy to control perineal sepsis. The healing time of the perineal wound was longer than six months in 83 percent of patients requiring rectal excision. We concluded that long-term catheter drainage may offer substantial benefit in the overall outcome of the treatment of patients with Crohn's disease and perirectal abscess.Read at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Ontario, Canada, June 11 to 16, 1989.     

Perianal Paget's disease

Fewer than 100 cases of Paget's disease located in the perianal skin have been reported since the extramammary location was first described in 1893. Two patients seen and treated in the authors' institutions with disease limited to the epidermis and its adnexae are described to illustrate the usual presentation and pathobiology of the disease. A staging classification based on the disease pathology has been developed from the cases reported in the literature and correlated with appropriate surgical treatment. Stage I disease treated with wide local excision promises unlimited survival, whereas the prognosis worsens for Stage II, with synchronous localized malignancies, and for Stages III and IV, with regional and distant metastatic disease, respectively.     

Surgery for symptomatic hemorrhoids and anal fissures in Crohn's disease

This study was undertaken to determine the outcome of surgery for symptomatic hemorrhoids and anal fissures in patients with known Crohn's disease. Seventeen patients underwent surgery for symptomatic hemorrhoids. Fifteen of these 17 patients' wounds healed without complication. Twenty-five patients underwent 27 operations for anal fissures. Twenty-two of these patients had uncomplicated wound healing by two months. Long-term follow-up, which was at a mean of 11.5 years in the hemorrhoid patients and 7.5 years in the fissure patients, revealed that only three patients required proctectomy, none as a direct result of surgery. Patients with severe symptoms secondary to anal fissures and hemorrhoids, who are known to have Crohn's disease and who cannot be controlled with conservative medical management, may undergo surgery on a highly selective basis when the disease is in the quiescent state. Proctectomy is not an inevitable outcome.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.     

Factors related to frequency,type, and outcome of anal fistulas in Crohn's disease

PURPOSE: Relation of clinical factors to frequency, type, and, in particular, outcome of anal fistulas in Crohn's disease was studied. METHODS: One hundred twelve patients seen in this hospital between January 1972 and June 1993 who suffered from Crohn's disease were included in the study. Those 35 (31 percent) with anal fistulas were reexamined or interviewed and asked about their perianal symptoms and anal control. RESULTS: Rectal involvement of Crohn's disease was associated with an increased incidence of anal fistula (49 vs. 17 percent;P <0.01), especially high ones (82 vs. 17 percent;P <0.01). Ten of 18 patients with low fistulas underwent fistulotomy; all 10 fistulas healed, but slowly (mean healing time, 7.5 months), and 4 of them recurred. Of eight low fistulas managed by drainage alone, four healed. Finally, 11 of 18 patients with low fistulas had their fistulas healed. Fourteen of 17 patients with high fistulas were primarily treated by drainage and 3 by local surgery. Finally, only three patients had healed fistulas—two after simple drainage and one after local surgery, and seven patients had to undergo proctectomy. Only two patients with low fistulas required proctectomy. Eight patients (33 percent) of those 24 with fistulas in whom anal continence could be assessed, 5 with local surgery and 3 with drainage alone, reported minor defects in anal control. CONCLUSIONS: Fistulotomy is a justifiable option with satisfactory results for low symptomatic anal fistulas associated with Crohn's disease, although healing may be delayed and some fistulas will recur. Outcome of high fistulas is less satisfactory, and proctectomy is ultimately required in a number of patients; therefore, for high fistulas a conservative approach is primarily recommended.     

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.     

Surgical recurrence of perforating and nonperforating Crohn's disease

PURPOSE: This is a study of the long-term course of surgically treated Crohn's disease designed to identify prognostic factors predictive of the time course and probability of surgical recurrence. PATIENTS AND METHODS: The study is based on the records of 101 patients admitted to our institution for surgical treatment of Crohn's disease from January 1, 1970, to December 31, 1985. Follow-up was complete in 97 (96 percent) and incomplete in 4 patients. Median follow-up from the date of first operation was 13.25 years. The cumulative probability of requiring surgical treatment for recurrent disease was calculated using the life table method and further analyzed with the log-rank test and Cox regression. RESULTS: The time to reoperation in this series was not significantly influenced by sex, age at onset of symptoms, age at diagnosis, age at first operation, anatomic location, and number of sites involved at the time of first operation. The only variable that had a statistically significant effect on the time to reoperation was characterization of disease at the time of operation as being perforating (P) opposed to nonperforating (NP). Median interval between the first and second intestinal operation was 1.7 years for the P group and 13 years for the NP group (P value, 0.005),and the median time between any two operations undergone during the study period was 2 years for the P group and 9.9 years for the NP group (tP =0.0002).The risk of having to undergo reoperation for recurrence was greatest during the first two years after an operation, and this was mainly because of a short time to surgical recurrence in the P group of indications. Thereafter, the yearly hazard of requiring further surgery was maintained at approximately 5 percent. CONCLUSION: The cumulative probability of requiring a reoperation for patients undergoing surgery for the P type of Crohn's disease is significantly different from that of patients with NP indications. The risk of having to undergo further surgery is particularly high during the first two years following an operation for perforating disease. The concept of a relatively aggressive perforating type of Crohn's disease and a more indolent nonperforating type is confirmed by the results of this study.Supported by the Funds for Clinical Research of the Kantonsspital Aarau.     

Crohn's disease in the Chinese population

PURPOSE: Crohn's disease was extremely rare among Chinese. We reviewed all cases diagnosed as having Crohn's disease during a five-year period. METHODS: A diagnosis of Crohn's disease was made only if all of the following criteria were fulfilled: 1) clinical symptom(s) and sign(s) compatible with chronic inflammatory bowel disease; 2) exclusion of intestinal infection by repeated stool cultures; 3) macroscopic features of small and/or large intestinal inflammation with skip lesion, stricture, and fistula formation; 4) histologic features of Crohn's disease,i.e., focal lymphoid aggregate, focal cryptitis, and granuloma formation; 5) clinical response to conventional therapy for inflammatory bowel disease. RESULTS: Fifteen ethnic Chinese patients were diagnosed as having Crohn's disease in this period. All patients had colitis, whereas small intestine inflammation was documented in only 47 percent of patients. Extraintestinal manifestations were uncommon except for arthropathy: ankylosing spondylitis (2), sacroiliitis (1), juvenile rheumatoid arthritis (1), and colitic arthritis (1). The majority of our patients responded to medical therapy. Surgery was undertaken in 33 percent of patients. CONCLUSION: Although there is a general increased incidence of Crohn's disease in the Western world, we too are beginning to see more cases in the Far East. Nevertheless, gastrointestinal infection with bacteria and/or parasites should still be carefully excluded in these countries.Presented in abstract form at the IX Asian-Pacific Congress of Gastroenterology, December, 1992.     

Colorectal adenocarcinoma in Crohn's disease

PURPOSE: The aim of this study was to review all histopathologic sections from surgical specimens with inflammatory bowel disease and colorectal carcinoma filed at this hospital between 1951 and 1996. METHOD: A total of 40 surgical (n=39) or autopsy (n=1) colon or colorectal specimens were reviewed. Internationally accepted histologic criteria were strictly applied to differentiate Crohn's disease (CD), ulcerative colitis (UC), and indeterminate colitis (IC). RESULTS: Of the 40 specimens with inflammatory bowel disease and carcinoma, 22 (55 percent) had CD, 16 (40 percent) had UC, and the remaining 2 (5 percent) had IC. Males accounted for 72.7 percent or 16 of the 22 patients with colorectal carcinoma in CD and for 68.7 percent or 11 of the 16 patients with carcinoma in UC. Both patients with IC and carcinoma were males. The median age of patients at diagnosis was as follows: CD, 20 (range, 7–68) years; UC, 23 (range, 5–21) years. In IC, the age was 61 and 81 years, respectively. The median disease duration (before detection of colorectal cancer) was as follows: CD, 18.5 (range, 1–45) years; UC, 19 (range, 6–38) years. For cases with IC, it was 13 and 19 years, respectively. Median age of patients at cancer diagnosis was as follows: CD, 48 (range, 21–78) years; UC, 49 (range, 21–81) years. Ages at cancer diagnosis in IC were 68 and 81 years. Colorectal carcinoma tend to develop among relatively young patients with CD and UC. Mucinous adenocarcinomas accounted for approximately one-third of the carcinomas affecting CD. Thirty percent of old specimens (before the end of 1982) had in fact carcinoma complicating CD and not UC (the latter being the diagnosis appearing in old pathologic reports). During a time lapse of 38 years (i.e.,between 1951 and 1989), only 11 cases of colorectal CD with carcinoma (i.e.,0.2 cases/year) were found, but as many as 11 during the past 6.5 years (i.e.,1.7 cases/year) have been diagnosed. Only 42.3 percent (11/26) of cases with colorectal inflammatory bowel disease and carcinoma operated on between 1951 and the end of 1989 had Crohn's colitis but as many as 78.6 percent (11/14) of those operated on between 1990 and May 1996 had Crohn's colitis. Review of the literature indicated that 64.8 percent or 191 of the 295 cases of colorectal carcinomas in CD so far reported occurred in the past 6.5 years. It would seem as if the risk of colorectal carcinoma in Crohn's colitis has increased in later years. CONCLUSIONS: 1) Reports on cancer frequency in UC based on old histopathologic records should be subjected to critical histologic re-evaluation; 2) carcinoma in Crohn's colitis has increased at this hospital, particularly since 1990; 3) the surveillance program strategy used in patients with long-standing UC at this hospital should also embrace patients with Crohn's colitis.Supported by the Cancer Society and the Karolinska Institute, Stockholm, Sweden.     

Stapled strictureplasty for Crohn's disease

Stapled strictureplasty has been performed on 26 occasions in 22 patients. In contrast with sutured strictureplasty, there were no major postoperative complications. The use of staples provides a method of identifying whether recurrence is at the strictureplasty site. Stapled strictureplasty avoids an enterotomy through recurrent disease and may have advantages over conventional sutured strictureplasty.     

Adenocarcinoma complicating Crohn's disease

We report on 14 cases of intestinal adenocarcinoma complicating Crohn's disease, seven occurring in the small bowel and seven in the large bowel. In both locations, two-thirds of patients were male. The average ages at the time of diagnosis of Crohn's disease and of cancer were similar between the two groups of patients: 28 and 48 years, respectively. The diagnosis of cancer was suspected or obtained preoperatively in only four cases of large bowel cancer; in two patients with large bowel cancer and five with small bowel cancer, the diagnosis was made at laparotomy. In the remaining cases, only careful histologic examination revealed the carcinoma. Six small bowel cancers were located in the ileum, and five colonic cancers were distal to the splenic flexure. Two small bowel and one large bowel cancer were multifocal and had surrounding mucosal dysplasia. All tumors, except one small bowel cancer, underwent resection. Survival correlated with stage of tumor at resection; no patient with regional or distant metastasis survived five years, in comparison with an 83 percent five-year actuarial survival rate of patients with tumor confined to the intestinal wall. Mean survival was six months for patients with small bowel cancer in comparison with 65 months for patients with large bowel cancer, reflecting a tendency toward more advanced lesions in the small bowel cancer group.     

Incidence of surgical resection for Crohn's disease

One hundred fifty-two of 399 Crohn's patients (38 percent) diagnosed over 20 years, who lived within a geographically defined area at the time of diagnosis, underwent at least one operation. One hundred seventy-one resections were performed in 160 operations during a mean follow-up of 60 months. Forty-eight percent of patients had undergone their first resection within 10 years of diagnosis, and 39 percent of these had undergone a second resection within 10 years of the first. There was no difference between smokers and nonsmokers in the timing of their surgery.     

Selected operative management of fistula-in-ano in Crohn's disease

PURPOSE: The operative management of patients with fistula-in-ano in the presence of Crohn's disease has been controversial. Our aim was to review the results of operative treatment in this clinical setting. METHODS: Twenty-eight such patients treated between 1976 and 1990 were reviewed. The duration of local symptoms, location of the Crohn's disease, medications, and previous operations were noted. An effort was made to classify the fistula-in-ano according to Parks' classification, but many fistulas were complicated and did not neatly fit into one of the described categories (intersphincteric 9, transsphincteric 10, complex 9). Patients underwent fistulotomy (three with a seton). RESULTS: Complete healing was achieved in 71.4 percent of cases with an average healing time of 3.5 months (range, 3 weeks-26 months). With an average follow-up of 71 months (range, 12 months-14 years), postoperative function was good in 20 (71.5 percent) patients. Of the remaining eight patients, five ultimately underwent total proctocolectomy because of the severity of their colorectal disease, one patient developed alteration of continence, and two patients developed stenosis. There were two recurrences, (one at nine months and one at six years). CONCLUSION: Operative treatment should be offered to selected patients with fistula-in-ano in the presence of Crohn's disease.Supported by the Sir Mortimer B. Davis-Jewish General Hospital Research Foundation.Read at the Tripartite Colorectal Meeting, Sydney, Australia, October 17 to 20, 1993.