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.     

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.     

Surgical management of ileosigmoid fistulas in Crohn's disease

Ileosigmoid fistulas are found in Crohn's disease and may present a surgical dilemma. PURPOSE: This study was designed to examine surgical practice to determine types of intervention, enumerate complications, and elicit guidelines for surgical management. METHOD: The medical records of patients with ileosigmoid fistula and Crohn's disease from 1975 to 1995 were reviewed. RESULTS: Ninety patients (44 men) were studied. A preoperative diagnosis of ileosigmoid fistula was made in 77 percent of patients. Sigmoid repair was performed in 43 patients (47.8 percent), sigmoid resection in 32 patients (35.6 percent), 12 patients (13.3 percent) underwent more extensive procedures, and 3 patients (3.3 percent) either had surgery elsewhere or were observed. The fistula was never directly responsible for a stoma. The repair and resection groups were similar with respect to age, length of Crohn's disease, and preoperative symptoms. There was no significant difference between groups in the incidence of postoperative complications; there were no postoperative deaths. Average length of stay was 8.3 days following repair and 9.9 days after resection. Reasons for resection included significant purulence or inflammation, a large fistula defect, a defect on the mesenteric border of the sigmoid, and active sigmoid Crohn's disease. Surgeon's assessment of the presence of Crohn's disease in the sigmoid correlated with pathologic examination and was aided by knowledge of recent endoscopic appearance and biopsy results; intraoperative frozen section and colonoscopy were helpful in distinguishing serosal inflammation from active Crohn's disease. CONCLUSION: Contrast studies identified 77 percent of ileosigmoid fistulas preoperatively. Performing repair rather than resection does not increase the risk of complications, if standard surgical principles are followed. Preoperative or intraoperative endoscopy assists the surgical evaluation of the sigmoid.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Surgical treatment of enterovesical fistulas in Crohn's disease

A review of the surgical treatment of enterovesical fistula in Crohn's disease was undertaken to evaluate its effectiveness and long-term results. Sixty-three patients, 39 men and 24 women, with a mean age of 34.4 years were identified with enterovesical fistula. They had documented Crohn's disease for a mean period of 7.0 years. Distribution of anatomic pattern was 34.9 percent ileal, 7.9 percent colonic, and 57.2 percent ileocolic. Nineteen (30.1 percent) had previous abdominal surgery for Crohn's disease. Presenting symptoms included frequency and dysuria in 93.6 percent, pneumaturia in 79.3 percent, and fecaluria in 63.4 percent; 60.3 percent of patients had all three features. Enterovesical fistula was confirmed preoperatively in 43 patients, suspected clinically in 15 patients, and diagnosed intraoperatively in 5 patients. Sixty-one of 63 patients underwent surgery with resection of the phlegmon or abscess with the diseased bowel and curettage or resection of the fistula. After curettage of the bladder defect, pelvic and bladder drainage was instituted. Coexistent fistulas, most commonly ileosigmoid, occurred in 31 patients. Intra-abdominal abscesses were found in 21 patients, of whom 15 required two-stage procedures. One patient died (mortality 1.6 percent), urine leak occurred in 3.2 percent, and wound infection occurred in 1.6 percent. Follow-up (mean, 106 months) has identified one recurrence of enterovesical fistula due to Crohn's disease, and a further recurrence from concomitant sigmoid diverticulitis. Enterocutaneous fistulas developed in 6.4 percent and 11 patients (17.4 percent) have required further resections for Crohn's disease. Surgical treatment of enterovesical fistula in Crohn's disease is a safe and effective treatment.Study performed at The Cleveland Clinic Foundation.Read at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.     

Clinical course of Crohn's disease in older patients

The authors retrospectively reviewed the records of 50 patients whose initial diagnosis of Crohn's disease was made after the age of 50 years on the basis of strict histopathologic criteria. Progress of the 32 women and 18 men with a median age of 60 years (range, 50 to 78 years) was followed for a median of 95.5 months (range, 81.1 to 236.6 months). The most common presenting signs and symptoms were abdominal pain (82 percent), diarrhea (70 percent), weight loss (56 percent), bleeding from the gastrointestinal tract (26 percent), abdominal mass (16 percent), and fistula (14 percent). Initial operations performed were ileocolic resection (38 percent), proctocolectomy (16 percent), small bowel resection (10 percent), colostomy (2 percent), and a variety of segmental resections of the colon (34 percent). The overall recurrence rate of disease in patients in whom all obvious disease was resected, based on distribution of disease, was 80 percent (ileocolitis), 38 percent (ileitis), and 35 percent (colitis). Crohn's disease more often affects the distal gastrointestinal tract in older age groups. After resection, however, the clinical course is similar to that of the younger population. The high recurrence rate of Crohn's colitis is probably a result of the large number of initial segmental resections.Read at the Annual Meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.     

Seton management of complex anorectal fistulas in patients with Crohn's disease

Anorectal fistulas associated with Crohn's disease are difficult to manage, particularly when the rectum is diseased. Significant morbidity has been associated with both medical and surgical therapy. Although conventional therapy is acceptable in the management of simple fistulas in Crohn's disease, these approaches often exacerbate rather than ameliorate problems in patients with complex fistulas. The authors report ten cases of complex fistulas in patients with Crohn's disease managed with their technique of long-term, indwelling setons. These setons are placed through the fistula tract and tied loosely to maintain the patency of the fistula without cutting through the sphincters. At the time of insertion, although abscesses are incised and drained, no attempt is made to divide the superficial tissues or sphincter overlying the fistulous tract. The patients ranged in age from 23 to 81 years and had a history of Crohn's disease for 1 to 20 years. All cases resulted in excellent palliation. No patient required a proximal colostomy. These patients have been followed for four months to seven years. Despite severe proctitis in six of these patients at the initial operation, no patient has required a proctectomy. The authors believe this technique achieves adequate palliation and should be employed as the procedure of choice in patients with complex anal fistulas associated with Crohn's disease.     

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.     

Strictureplasty for ileocolic anastomotic strictures in Crohn's disease

PURPOSE: Because of the limited experience, the use of strictureplasty for a strictured ileocolic anastomosis associated with Crohn's disease was reviewed. METHODS: We reviewed 22 patients who had a strictureplasty to treat symptomatic ileocolic anastomotic strictures related to Crohn's disease. The median interval between a previous ileocolic anastomosis and strictureplasty was 2 years (range, 1 to 26 years). The median age was 39 years and there were 15 males and 7 females. The median followup was 2 years. RESULTS: Strictureplasty on a strictured ileocolic anastomosis was either a Heineke-Mikulicz (n=15) or a Finney (n=7) strictureplasty. Fifteen (68 percent) patients needed 47 additional strictureplasties in other sites of the small bowel and 5 (23 percent) patients had synchronous small bowel resection mainly for separate areas of phlegmonous disease. Only five (23 percent) patients did not have a synchronous procedure on the small bowel. There was no mortality or major septic complications. After surgery, relief of obstructive symptoms was noted in all patients. The median weight gain at six months after surgery was 3 kg (range, –5 to +10 kg) and 75 percent of the patients were weaned off steroids. Symptomatic recurrence occurred in two (9 percent) patients from new strictures at sites unrelated to previous strictureplasties; only one needed reoperation for recurrence. Patency of the strictureplasty on ileocolic anastomosis in asymptomatic patients was confirmed by small bowel contrast study (n=12) and colonoscopy (n=4). CONCLUSIONS: Strictureplasty preserves small bowel length and may be a viable alternative to repeat ileocolic resection in suitable cases     

Surgical management of ileosigmoid fistulas in Crohn's disease: Role of preoperative colonoscopy

PURPOSE: Surgical treatment of ileosigmoid fistulas in Crohn's disease remains controversial and can be radical (resection of both segments) or conservative (ileal resection with suture or wedge resection of the sigmoid). At our institution, the sigmoid defect is sutured if the sigmoid is not affected by primary Crohn's disease or by important stricture; otherwise, the sigmoid is resected. We reviewed our experience to evaluate our results with this procedure. METHODS: Thirty patients with ileosigmoid fistulas underwent operation. Among them, 15 had a preoperative colonoscopy, whereas others had no Endoscopic work-up. In nine patients, the sigmoid was thought to be affected by Crohn's disease (n = 7) or stricture (n = 2) and was resected. In 21 patients, the sigmoid was thought to be affected by proximity, and a simple suture (n = 15) or wedge resection (n = 6) was performed. Eleven patients had a temporary stoma (37 percent). One had coloproctectomy. RESULTS: One patient died postoperatively. One patient had postoperative sigmoidocutaneous fistula after conservative treatment. Histology of the sigmoid specimen showed Crohn's disease in 8 patients (27 percent), including 5 of 9 resected specimens, and 3 of 21 conservative procedures. All patients with Crohn's misdiagnosis did not have preoperative colonoscopy. Nine of 11 stomas were closed in a median delay of four months. With a median delay of nine years, four patients have again undergone surgery for recurrent colonic Crohn's disease, all of whom underwent surgery initially without preoperative colonoscopy. CONCLUSION: Preoperative Endoscopic assessment of the colon is a reliable guide to use when choosing between sigmoid resection or a conservative approach and can result in reduced morbidity and improved long-term results.     

Crohn's disease and adenocarcinoma of the intestinal tract

Four patients with intestinal adenocarcinoma complicating Crohn's disease are reported. The youngest of the four patients was a 21-year-old female with a 9-year history of Crohn's disease of the terminal ileum as well as of the entire colon. She developed mucus-producing moderately differentiated adenocarcinoma in the cecum. Of the remaining three patients with Crohn's disease, one presented an adenocarcinoma in the ascending colon, one in the rectum and the remaining one in the duodenum. All three colorectal adenocarcinomas originated in areas of high-grade dysplasia and all four in areas with chronic transmural inflammation. The review of the literature indicates that a total of 174 small and large bowel cancers occurring in Crohn's disease have been recorded (including the four reported herein). The vast majority of the reported cases have been found in the North American subcontinent. Only in a few instances were bowel adenocarcinoma and Crohn's disease observed in the European continent. It is therefore remarkable that three of our four cases were seen within a period of 12 months. Interestingly, six patients having colorectal adenocarcinoma in association with Crohn's disease were recently reported from a single hospital in England. The question therefore arises whether our cases and those reported recently from England are unrelated and merely coincidental or whether carcinomas are now also affecting European CD patients. If the latter is the case, the surveillance policy for patients with CD should be reconsidered at this hospital.This study was supported by grants from the Karolinska Institute and Cancer Fonden.     

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.     

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.     

Fecal diversion in the management of Crohn's disease of the colon

The clinical course of 44 patients undergoing elective proximal fecal diversion for Crohn's disease of the colon is reported. Sustained disease remission was obtained in 31 patients (70 percent). Diversion was associated with a significant reduction in steroid requirements (P<0.01) and a significant improvement in hemoglobin (P<0.001), erythrocyte sedimentation rate (P<0.001), and albumin (P<0.05). Sixteen patients (36.4 percent) have required a proctocolectomy, 19 patients (43.2 percent) remain defunctioned, and four patients (9 percent) have died. Five patients have had intestinal continuity restored, which has remained intact in four patients for a mean follow-up of 99 (range 21–153) months. Fecal diversion for Crohn's disease of the colon produces a high incidence of sustained disease remission, but for the majority of patients the prospect of future restoration of intestinal continuity is limited.     

Gastrointestinal malignancies in Crohn's disease

The relationship between gastrointestinal neoplasms and Crohn's disease is poorly defined. The purpose of this study was to characterize the features of gastrointestinal malignancies that developed in Crohn's patients. In this retrospective review the authors identified six patients with Crohn's disease who developed such lesions over a 20-year period: four patients had colorectal cancers and two had ileal malignant neoplasms. Patients averaged 52.7 years of age (range, 21 to 61 years). Three patients were men and three women. Five of the six patients had endured Crohn's disease for more than 20 years. Only two lesions were diagnosed before surgery. The colorectal lesions were predominantly right-sided and all occurred in bowel segments with active Crohn's disease. The lesions demonstrated aggressive histologic features: three of six tumors were poorly differentiated, one of the five adenocarcinomas was mucinous, and three of the colorectal cancers were Dukes' B or C lesions. Four of six patients survived five or more years. There was a single malignant carcinoid, which represents the seventh case report of a carcinoid tumor occurring in a patient with Crohn's disease. This study indicates that patients with Crohn's disease develop a wide variety of small bowel and colorectal cancers. Furthermore, it suggests that Crohn's patients with colonic disease should periodically undergo surveillance colonoscopy.     

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.     

Clinical classification of perianal Crohn's disease

Assessment of the efficacy of therapeutic approaches to anal lesions of Crohn's disease is frustrated by the lack of precise definition of its various manifestations. A classification that is clinical and based on anatomic and pathologic aspects is presented; it has been derived from a 20-year prospective study of anal Crohn's disease in Cardiff. Conceptually, the classification is analogous to the TNM system for cancer. The main classification (U.F.S.) defines the presence of Ulceration, Fistula/abscess, and Stricture, qualified by numeric values reflecting severity (0=not present, 1=limited clinical impact, and 2 =severe). A subsidiary classification (A.P.D.) defines Associated conditions, Proximal intestinal involvement, and Disease activity. In addition, the classification may be used in a detailed form for research or comparative purposes or in a simple form defining only the dominant lesions for routine clinical use. General use of the classification would make it possible to compare in detail incidence, management, and results of treatment in different centers.     

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.     

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.     

Concordance of familial characteristics in Crohn's disease and ulcerative colitis

The diagnosis of inflammatory bowel disease (IBD) in a proband increases the probability of a parallel IBD diagnosis in a family member. In this study, we were able to confirm the IBD diagnosis in 35 (9.9 percent) of the relatives of 352 registry probands. To confirm a proband's report of a positive family history of IBD, efforts were made to directly contact all first-degree relatives regardless of their IBD status (parents, siblings, and children). Consent to contact family members was obtained from the proband, who furnished the registry personnel with names, addresses, and phone numbers. We then attempted to contact each identified relative by phone. After verbal consent was obtained, family members were asked if they had been diagnosed with IBD. This diagnosis was confirmed by contacting the relative's physician. A McNemar (² _Mc) matched-pair analysis was used to analyze concordance between the proband and the affected family member. Within the CD/CD (Crohn's disease) concordant pairs, sex was a significant risk factor. Sex was not a significant risk factor within the UC/UC (ulcerative colitis) concordant pairs. In the condordant surgery pairs, no surgical procedure was a significant risk factor for the prediction of a similar surgical procedure for the affected relative. In concordant extraintestinal complications, only the appearance of a skin rash was significantly related to the appearance of a skin rash in the affected relative.Supported by a grant from The Dorothy Rider Pool Health Care Trust.     

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.